y ■ 

■ 




A TREATISE 



DISEASES 



INFANCY AND CHILDHOOD 



J. LEWIS SMITH, M.D.. 

CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN BELLEVUE HOSPITAL MEDICAL 
COLLEGE ; PHYSICIAN TO CHARITY HOSPITAL ; PHYSICIAN TO THE N. Y. 
FOUNDLING ASYLUM ; CONSULTING PHYSICIAN TO THE N. Y. 
INFANT ASYLUM ; CONSULTING PHYSICIAN TO THE 
CLASS OF CHILDREN'S DISEASES, BUREAU 
FOR THE RELIEF OF THE OUT- 
DOOR POOR, BELLEVUE. 



FIFTH EDITION, THOROUGHLY REVISED, 



WITH ILLUSTRATIONS. 




/6 v*7r>^ 






PHILADELPHIA: 
HENRY 0. LEA^S SOjST & CO. 

1881. 




Entered according to Act of Congress, in the year 1881, by 

HENRY C. LEA'S SON & CO., 

in the Office of the Librarian of Congress. All rights reserved, 



PREFACE. 



The constant endeavor of the author, as successive editions of 
this treatise have been called for, has been to make it more use- 
ful to the medical student and to the physician in his daily 
practice. He has avoided discussion of theories, except as they 
influence practice, while he has devoted more space to the 
therapeutics of the various diseases. He has been stimulated to 
this by constant intercourse with physicians, so as to be able to 
appreciate their wants, and by letters of inquiry sent by physicians, 
which, for the most part, relate to matters of treatment. 

The text has been considerably enlarged, though, in conse- 
quence of a change of type, the bulk of the book is not materially 
increased. The reader familiar with the last edition will observe 
that a few additional diseases have been treated of ; for a clear 
and succinct description of one of which, to wit, strumous ophth- 
almia, the author is indebted to Dr. O. D. Pomeroy, Surgeon to 
the Manhattan Eye and Ear Infirmary. 

J. L. S. 

No. 227 West 49th Stkeet, New York, 
September 16, 1881. 



CONTENTS 



PAKT I. 



CHAPTER I. 

PACK 

Infancy and Childhood , . . .17 

CHAPTER II. 
Care op the Mother in Pregnancy 19 

CHAPTER III. 
Mortality of Early Life — its Causes and Prevention ... 24 

CHAPTER IV. 

Weight, Growth, Lactation 29 

Hindrances to Lactation and Physical Conditions rendering it Improper 
— Colostrum— Human Milk — Modification of the Milk in consequence 
of the Diet — Modification of Milk from its Retention in the Breast — 
Modification of Milk by Age and by Mental Impressions — Modifica- 
tion of Milk by the Catamenial Function and Pregnancy — Differences in 
Suckling Women as regards Quantity and Quality of Milk — Scantiness 
of Milk ; its Causes and Treatment . 

CHAPTER V. 
Selection of a Wet-Nurse 48 

CHAPTER VI. 
Course of Aactation — Weaning .... . 52 



VI CONTENTS. 

CHAPTER VII. 

PAGE 

Quantity of Food required in Infancy and Childhood 55 

CHAPTER VIII. 

Artificial Feeding 61 

Composition of Milk. 

CHAPTER IX. 

Bathing, Clothing, Sleep, Exercise 68 

Clothing — Sleep — Exercise. 

CHAPTER X. 

Accidents and Ailments incidental to the Birth of the Infant, 

and Detachment of the Cord 74 

Apncea (Asphyxia) Neonati — Caput Succedaneum — Cephalaematoma. 

CHAPTER XI. 

Ophthalmia Neonati . . 77 

Causes — Symptoms— Treatment . 

CHAPTER XII. 

Diseases of the Umbilicus 83 

Inflammation and Ulceration of Umbilicus — Treatment — Umbilical 
Granulations or Fungus — Treatment. 

CHAPTER XIII. 

Umbilical Hemorrhage 85 

Sex — Age — Causes — Symptoms— Prognosis — Treatment. 

CHAPTER XIV. 

Diagnosis of Infantile Diseases ........ 89 

General Observations— Features, External Appearance of Head, Trunk, 
and Limbs in Disease — Attitude — Movements — The Voice — Respiratory 
System— Respiration in Health— Respiration in Disease— Circulatory 
System— Pulse in Health— Pulse in Disease— Animal Heat— Digestive 
System — Nervous System. 

CHAPTER XV. 
Therapeutics ,,,..* 101 



CONTENTS. Vll 



PART II. 

CONSTITUTIONAL DISEASES 

SECTION I. 
DIATHETIC DISEASES. 



CHAPTER I. 

PAGE 

Rachitis 103 

Age — Causes — Anatomical Characters : First Stage; Seco ad Stage — 
Craniotabes ; Third Stage — Symptoms — Complications — Diagnosis — 
Prognosis — Treatment . 



CHAPTER II. 

Scrofula 120 

Causes — Anatomical Characters — Symptoms — Relation of Scrofulosis 
to Tuberculosis — Prognosis — Treatment : Prophylactic ; Curative — 
Strumous Ophthalmia — Treatment. 



CHAPTER HI. 

Tuberculosis 143 

Etiology — General Anatomical Characters of Tuberculosis— Anatomi- 
cal Characters in Infancy and Childhood — Lungs— Abdominal Viscera 
— Stomach and Intestines — Symptoms — Encephalon — Bronchial Glands 
— Physical Signs — Lungs — Pleura — Stomach and Intestines — Diagnosis 
— Prognosis — Treatment : Prophylactic ; Curative . 



CHAPTER IV. 

Syphilis 167 

Etiology — Clinical History — Coryza — Mucous Patches — Roseola — Pem- 
phigus — Acne, Impetigo, and Ecthyma— Visceral Lesions — Osseous 
Lesions — Prognosis — Treatment . 



Vlll CONTENTS. 

SECTION II. 
ERUPTIVE FEVERS, 



CHAPTER I. 

PAGE 

Measles 178 

Symptoms — Complications — Anatomical Characters — Nature — Diagno- 
sis — Prognosis — Treatment . 



CHAPTER II. 

Scarlet Fever 187 

Symptoms : Regular Form ; Irregular Form ; Malignant Form— Com- 
plications — A Case— Sequelae — Otitis — Anatomical Characters — Nature 
—Diagnosis— Prognosis— Treatment— Prophylaxis— Care of Patients 
— Infected Articles. 



CHAPTER III. 

ROTHELN 216 

Premonitory Stage — Symptoms— Tegumentary System — The Skin — 
Mucous Membrane — The Respiratory System — The Digestive System — 
The Pulse and Temperature — Complications — Prognosis — Nature — In- 
cubative Period — Contagiousness. 



CHAPTER IV. 

Variola — Varioloid 225 

Variola — Incubative Period — Stage of Invasion — Stage of Eruption — 
Stage of Desiccation — Varioloid — Mode of Death — Anatomical Charac- 
ters — Complications — Prognosis — Diagnosis — Treatment. 



CHAPTER V. 

Vaccinia 236 

Appearances — Symptoms — Anomalies, Complications, and Sequels — 
Subsequent Vaccinations — Revaccination — Selection of Virus . 



CHAPTER VI. 

Varicella 246 

Symptoms — Diagnosis — Prognosis — Treatment. 



CONTENTS. IX 

SECTION III. 
NON-ERUPTIVE CONTAGIOUS DISEASES. 



CHAPTER I. 

fAGE 

Diphtheria 248 

Age — Incubation — Nature — Cases — Anatomical Characters — Cases — 
Symptoms — Diagnosis — Prognosis — Treatment — General Treatment: — 
Stimulants — Local Treatment — Diphtheritic Croup — Preventive Meas- 
ures. 

Pertussis 295 

Age Causes — Pathological Anatomy — Symptoms — Second Period — 

Complications — Diagnosis — Prognosis — Treatment — Prophylaxis. 



CHAPTER II. 

Parotiditis 310 

Nature — Diagnosis — Treatment. 



. SECTION IV. 

OTHER GENERAL DISEASES. 

CHAPTER I. 

Intermittent Fever 313 

Symptoms — Treatment. 

CHAPTER II. 

Remittent Fever .318 

Symptoms — Diagnosis — Treatment . 

CHAPTER III. 

Typhoid Fever 320 

Causes — Anatomi cal Characters — Symptoms — Complications — Diag- 
nosis— D uration— Prognosis— Treatment . 

CHAPTER IV, 

Cerebro-Spinal Fever . . 328 

Cause — Sex — Age — Symptoms — Mode of Commencement — Symptoms 
pertaining to the Nervous System — Digestive System — Pulse — Tem- 
perature — Respiratory System — Cutaneous Surface — Nature — Prog- 
nosis — Diagnosis — Anatomical Characters — Treatment : Preventive ; 
Curative. 



CONTENTS. 
CHAPTER V. 



Acute Rheumatism 359 

Causes — Symptoms — Duration — Prognosis — Diagnosis — Treatment. 

CHAPTER VI. 

Erysipelas 366 

Table of Cases — Age — Point of Commencement — Causes — Premoni- 
tory Symptoms — Symptoms — Prognosis — Duration — Modes of Death — 
Pathological Anatomy — Treatment. 



PAET III. 

SECTION I. 
DISEASES OF THE C E RE B RO- S P I N AL SYSTEM. 

CHAPTER I. 

Acephalus— Anencephalus = . 377 

Anatomical Characters — Symptoms — Prognosis. 

CHAPTER II. 

Imperfect Brain 379 

Case — Symptoms — Prognosis — Microcephalus — Atrophy of Brain. 

CHAPTER III. 

Hypertrophy op Brain 382 

Pathological Anatomy — Causes — Symptoms — Cases — Diagnosis — Prog- 
nosis — Treatment. 

CHAPTER IV. 

Thrombosis in the Cranial Sinuses (Phlebitis) .... 387 

Anatomical Characters — Causes — Symptoms — Diagnosis — Prognosis- 
Treatment. 

CHAPTER V. 

Congestion op the Brain 391 

Causes— Symptoms— Anatomical Characters— Prognosis— Treatment. 



CONTENTS. XI 



CHAPTER VI. 



Tntra-Cranial Hemorrhage (Meningeal Hemorrhage — Cerebral 
Hemorrhage) 396 

Causes — Anatomical Characters — Cerebral Haemorrhage — Symptoms — 
Meningeal Haemorrhage — Diagnosis — Prognosis — Treatment. 



CHAPTER VII. 

Congenital Hydrocephalus 406 

A natomical Characters — Symptoms — Diagnosis — Prognosis — Treat- 
ment. 

CHAPTER VIII. 

Acquired Hydrocephalus .' . . . 413 

Causes — Anatomical Characters — Symptoms — Prognosis — Treatment . 



CHAPTER IX. 

Meningitis, Tubercular and Non-Tubercular 417 

Age — Pathological Anatomy — Causes — Premonitory Stage — Symp- 
toms — A Case — Diagnosis — Prognosis — Treatment. 



CHAPTER X. 

Spurious Hydrocephalus 437 

Anatomical Characters — A Case — Symptoms — Cases — Diagnosis — Prog- 
nosis — Treatment. 

CHAPTER XI. 

Eclampsia 442 

Causes — Premonitory Stage — Symptoms — Anatomical Characters — 
Diagnosis — Prognosis — Treatment. 



CHAPTER XII. 

Tetanus Infantum 453 

Fatal Cases — Favorable Cases — Period of Commencement — Frequency 
in Certain Localities — Causes — Symptoms — Mode of Death — Prognosis 
— Duration in Fatal Cases — Duration in Favorable Cases — Diagnosis — 
Preventive Treatment — Treatment. 



CHAPTER XIII. 

Internal Convulsions — Spasm of the Glottis — Laryngismus 

Stridulus 473 

Causes — Anatomical Characters — Symptoms — A Case — Diagnosis — 
Prognosis — Modes of Death — Treatment. 



Xll CONTENTS. 

CHAPTER XIV. 

PAGE 

Chorea 481 

Age — Causes — Sex — Uterine Irritation — Anaemia— Rheumatism — Mi- 
croscopic Appearances : Spinal Cord ; The Heart ; The Lungs — Fright 
— Imitation — Intestinal Irritation — Lesions of Brain and Spinal Cord 
— Anatomical Characters — Symptoms — Prognosis — Course — Diagnosis 
— Treatment : Regimenal ; Medicinal. 



CHAPTER XV. 

Infantile Paralysis 498 

Symptoms — Groups — Single Muscles — Prognosis — Progress — Etiology 
— Anatomical Characters — Diagnosis — Prognosis^Treatment. 



CHAPTER XVI. 

Facial Paralysis 510 

Causes — Symptoms — Prognosis — Treatment — Paralysis with Pseudo- 
Hypertrophy — Anatomical Characters — Causes — Prognosis — Treat- 
ment. 

CHAPTER XVII. 

Diseases op the Spinal Cord and its Coverings .... 515 
Congestion of the Spinal Cord and its Membranes— Anatomical Char 
acters — Symptoms — Treatment. 



CHAPTER XVIII. 

Spina Bifida 519 

Diagnosis — Prognosis — Treatment. 

CHAPTER XIX. 

Vertebral Caries . . 523 

Causes— Symptoms— Diagnosis— Prognosis— Treatment. 

SECTION II. 
DISEASES OF THE RESPIRATORY SYSTEM 



CHAPTER I. 

Anatomical Characters— Symptoms— Prognosis— Treatment. 



CORYZA 539 



CONTENTS. Xlll 

CHAPTER II. 

PAGE 

Catarrhal Laryngitis 532 

Symptoms — Anatomical Characters — Treatment — Spasmodic Laryn- 
gitis — Causes — Symptoms — Anatomical Characters — Pathology — Diag- 
nosis—Prognosis — Treatment. 

CHAPTER III. 

Pseudo-membranous Laryngitis 540 

Causes — Anatomical Characters — Symptoms — Pathological Characters 
— Diagnosis — Prognosis — Treatment. 

CHAPTER IV. 

Bronchitis 556 

Causes — Anatomical Characters— Symptoms — Diagnosis — Prognosis — 
Treatment. 

CHAPTER V. 

Atelectasis 569 

Acquired Atelectasis— Symptoms — Anatomical Characters — Treat- 
ment. 

CHAPTER VI. 

Pneumonitis 573 

Catarrhal, Croupous, and Interstitial — Causes — Anatomical Characters 
— Cheesy Pneumonitis — Symptoms — Physical Signs — Diagnosis — 
Prognosis — Treatment. 

CHAPTER VII. 

Pleuritis 588 

Causes — Cases — Anatomical Characters — Sero-fibrinous Pleuritis — 
Purulent Pleuritis — Hemorrhagic Pleuritis — Symptoms — Physical 
Signs — Palpation — Percussion — Auscultation — Diagnosis — Prognosis 
— Treatment — Nervous Cough — Treatment. 



SECTION III. 
DISEASES OF THE DIGESTIVE APPARATUS. 

CHAPTER I. 

Simple Stomatitis, Ulcerous Stomatitis, Follicular Stomatitis . 632 
Simple or Catarrhal Stomatitis — Causes — Symptoms — Appearances — 
Treatment — Ulcerous Stomatitis — Causes — Symptoms — Prognosis — 
Treatment— Aphthous Stomatitis — Causes — Symptoms — Diagnosis — 
Prognosis — Treatment. 



XIV CONTENTS. 

CHAPTER II. 

PAGB 

Thrush 638 

Anatomical Characters — Symptoms— Causes — Diagnosis — Prognosis — 
Treatment. 

CHAPTER III. 

Gangrene of the Mouth 643 

Anatomical Characters — Age — Causes — Symptoms — Diagnosis — Prog- 
nosis — Treatment. 

CHAPTER IV. 

Dentition . ... 650 

Pathological Results of Dentition — Diagnosis—Treatment— Second 
Dentition. 

CHAPTER V. 

Catarrhal Pharyngitis, Peri-pharyngeal Abscess, (Esophagitis . 658 
Anatomical Characters — Causes — Symptoms — Prognosis — Diagnosis — 
Treatment— Peri-Pharyngeal Abscess— Age— Cause— Anatomical Char- 
acters — Symptoms — Diagnosis— Prognosis — Treatment — (Esophagitis 
— Anatomical Characters — Treatment. 

CHAPTER VI. 

Indigestion, Congestion op Stomach, Gastritis, Follicular Gas- 
tritis, Diphtheritic Gastritis, Post-mortem Digestion, Soften- 
ing 669 

Causes — Symptoms — Prognosis — Treatment — Congestion of the Stom- 
ach — Gastritis — Cause — Age — A Case — Symptoms — Anatomical Char- 
acters — Diagnosis — Prognosis — Treatment — Follicular Gastritis — Diph- 
theritic Gastritis — Post-mortem Digestion, Softening — A Case. 

CHAPTER VII. 

DlARRHCEA ^85 

Non-Inflammatory Diarrhoea— Causes— Symptoms— Anatomical Char- 
acters — Prognosis — Treatment. 

CHAPTER VIII. 

Intestinal Catarrh of Infancy 690 

Causes— Age — Symptoms — Anatomical Characters— Diagnosis— Prog- 
nosis— Treatment : Regimenal Measures ; Medicinal Treatment ; Ene- 
mata ; External Treatment. 

CHAPTER IX. 

Enteritis and Colitis in Childhood 718 

Causes — Symptoms — Diagnosis — Prognosis — Treatment. 



CONTENTS. XV 

CHAPTER X. 

PAGE 

Cholera Infantum 721 

Causes — Symptoms — Anatomical Characters — Nature — Diagnosis — 
Prognosis — Treatment. 

Constipation 728 

Symptomatic Constipation — Causes — Case — Idiopathic Constipation — 
Causes — Symptoms — Treatment : Hygienic Measures ; Therapeutic 
Measures. 

CHAPTER XI. 

Intestinal Worms 744 

Ascaris Lumbricoides — Oxyuris Vermicularis — Taenia — Bothriocepha- 
lus latus — Trichocephalus dispar — Causes — Symptoms — Diagnosis — 
Prognosi s — Treatment. 

CHAPTER XII. 

Gastro-Intestinal Haemorrhage 762 

Three Varieties — A Case — Prognosis — Treatment. 



CHAPTER XIII. 

Intussusception 70s 

Intussusception without Symptoms — Intussusception with Symptoms — 
Previous Health — Causes — Age — Seat and Pathological Anatomy — In- 
tussusception in the Small Intestines — Cases — Intussusception in Large 
Intestines — Symptoms — Diagnosis — Duration — Prognosis — Modes of 
Death — Treatment. 



SECTION IV. 
DISEASES OF THE CIRCULATORY SYSTEM. 

CHAPTER I. 

Cyanosis 79S 

Literature of Cyanosis — Sex — Causes of the Malformations — Time of 
Commencement — Symptoms — Prognosis — Mode of Death — Modes of 
Compensation — Morbid Anatomy — Theories Relating to the Etiology 
of Cyanosis — Treatment. 



XVI CONTENTS. 

SECTION V. 
SKIN DISEASES 



CHAPTER I. 

PAGE 

Erythematous Diseases 811 

Erythema : Two Forms ; Idiopathic, Symptomatic — Prognosis — Diag- 
nosis — Treatment. Roseola : Symptoms — Causes — Prognosis — Diag- 
nosis — Treatment. Urticaria : Causes — Prognosis — Diagnosis — Treat- 
ment. 

CHAPTER II. 

Papular Diseases, Strophulus . 817 

Treatment. 

CHAPTER III. 

Eczema 819 

Anatomy — Etiology — Varieties — Symptoms — Course — Diagnosis — 
Treatment — Local Treatment — Scabies : Diagnosis — Treatment. 

Index 829 



THE 



DISEASES OF CHILDREN 



PART I 



CHAPTER I. 

INFANCY AND CHILDHOOD. 

Infancy and childhood are in certain respects the most important and 
interesting periods of life. To the physiologist they arc especially inter- 
esting, because they are the pciiods of development and of greatest func- 
tional activity ; to the pathologist, because in them many diseases occur 
which are rarely or never observed in the other periods, or which present 
in these periods peculiar features ; to the physician and vital statistician, 
because in them there is the Greatest amount of sickness and largest nuin- 
ber of deaths. 

Infancy extends from biith to the age of two and a half years, or till 
the completion of first dentition. In infancy the organs are delicately 
organized, containing a large proportion of water, and hence are easily in- 
jured. In this period the brain is rapidly developed — more so than any 
other organ ; animal matter predominates in the bones ; the arteries are 
relatively large, the muscles small ; the superficial veins are small. Fat is 
absent from the interior of the body, but abundant, in well-nourished 
infants, underneath the integument. The skin is delicate, and its tem- 
perature not much below that of the blood. At birth it has a reddish 
hue, and is covered with soft, fine hairs (lanugo). The reddish hue gradu- 
ally fades into the healthy tint of infancy, and the hairs fall out. In the 
first two months the sweat-glands have little functional activity, sensible 
perspiration being quite rare. Subsequently perspiration is freer, and, in 
certain diseased states (rachitis, etc.) is abundant. The sebaceous glands 
in the first half of infancy are active, particularly upon the scalp, produc- 
ing often a pale yellow incrustation, consisting of sebaceous matter and 
epidermic cells. 

The secretions from the mucous surfaces commence at an early period. 
At birth the surface of the digestive tube is covered with more or less 



18 INFANCY AND CHILDHOOD. 

mucus, often in considerable quantity. The meconium is not considered, 
as formerly, to be a product of intestinal secretion. It consists of flat 
epithelial cells, fine hairs, oil-globules, crystals of cholesterin, and brown- 
ish or yellowish masses of coloring matter probably from the liver. It 
is supposed that, with the exception of the coloring matter, the meconium 
is derived mainly from the amniotic fluid which the foetus has swallowed. 

The most wonderful change occurring in the system at birth, through the 
exigencies of the new life, is that in the circulation. The flow of blood 
being interrupted, thrombi form in the umbilical vein, and arteries, and in 
the ductus arteriosus, and ductus venosus, and these vessels gradually 
atrophy, becoming finally shrivelled but permanent cords. I have many 
times at autopsies removed the plug from the ductus arteriosus when death 
had occurred as late as the third week. The foramen ovale closes slowly. 
I have ordinarily found it open till near the end of the first half year, but 
the valve covers fully the aperture, so that there is no detriment to the 
circulation. Both the pulse and respiration are more frequent during in- 
fancy than childhood, and are more accelerated by moral and physical 
causes. 

The stomach has a smaller relative size and emesis more readily caused 
than in the adult. The liver is large, occupying at birth nearly half of the 
abdominal cavity, but it grows smaller in successive months. The appe- 
tite is good and digestion active, so that hunger, when appeased, soon re- 
turns. The thymus gland, at birth about the size of an unexpanded lung, 
slowly atrophies, but it does not totally disappear till after infancy. 

The kidneys, distinctly lobulated at birth, gradually change their form, 
so as to present in the last part of infancy nearly the shape of the organ in 
the adult. The renal secretion commences early, even before birth. The 
kidneys seldom undergo degenerative changes as in the adult, but they 
are liable to congestions and inflammations. During the first month, and 
especially the first fortnight, crystals of uric acid, and the urates, are often 
found in the urine, in a state of apparent health, causing more or less 
fretfulness in their elimination, staining the diaper, and not infrequently 
being arrested in the tubules of the pyramids, where they can be seen as 
pink-colored spots or lines (uric acid infarction). These deposits of uric 
acid and the urates may even occur in the foetus, producing obstruction 
and inflammation of the renal tubes. Congenital cystic degeneration of 
the kidneys is, in the opinion of Virchow, due to them. In early infancy 
the senses are imperfectly developed, the eyes being attracted only by 
bright objects, and the sense of hearing affected only by loud noises. 
Sleep is the normal state in the first weeks of life ; as the age of the infant 
increases, less and less sleep is required ; but the oldest infants need more 
than children, and several hours more than adults. 

The new-born infant is apparently destitute of mental faculties. It 
seeks the breast by instinct, and it exhibits no perception or reflection. 



CARE OF THE MOTHER IN PREGNANCY. 19 

The lond cries with which it commences its existence are not from anger 
or suffering ; they appear to he normal, like the act of nursing, and provi- 
dentially designed, in order to expand the lungs. It is not till the close^ 
or near the close, of the first month, that the gray substance of the brain 
begins to appear — the probable seat of the mind, and the source of all 
mental phenomena. Perception and curiosity are early manifested. The 
infant, as Edmund Burke has remarked, is constantly seeking new objects 
for its amusement, rejecting old playthings for such as possess more 
novelty. Reflection, a higher faculty of the mind, appears at a later 
period. The mind and the bodily organs in infancy are, in a high degree, 
impressionable. Anger is excited by trivial causes, but is easily ap- 
peased ; and the various functions in the system are disturbed by agencies 
which in youth or manhood would have no appreciable effect. 

Childhood extends from infancy to the age of fifteen years or puberty. 
It is a period of great physical activity, and of rapid growth. The func- 
tions of the various organs are performed with more moderation than in 
infancy, and arc less frequently deranged. The volume of the brain con- 
tinues to increase rapidly, and it becomes firmer than in infancy. It is 
estimated that by the seventh year the weight of this organ has doubled. 
The mind now exerts a controlling influence over the actions of the indi- 
vidual. The digestive organs have changed, so that solid food is required. 
Most of the glandular organs are less active than in the greater part of 
infancy, and some of them, as the liver, arc relatively smaller. The pulse 
and respiration gradually become less frequent as the child advances in age. 



CHAPTER II. 

CARE OF THE MOTHER IN PREGNANCY. 

The frequency of miscarriages and still-births, and the large number of 
ill-formed and puny infants, born to a precarious and short existence, 
render imperative, on the part of the mother, a strict observance of the 
laws of health, and an avoidance of all exciting or pcrturbating influences 
during the time when the foetus is being developed. The diet should be 
plain and easily digested, but nutritious. There is often a craving in 
pregnancy for unusual articles of food. These may sometimes be allowed 
within certain limits, provided that they arc such as do not derange the 
stomach. Meats and animal broths, together with vegetables and fari- 
naceous food, should constitute the ordinary diet, and should be taken at 
regular intervals. 

Daily exercise, never violent, but moderate and gentle, is requisite. 
No exercise is better, none safer and more likely to contribute to cheer- 



20 CARE OF THE MOTHER IN PREGNANCY. 

fulness and healthy functional activity of the organs, than the ordinary 
household duties. Lifting heavy weights, or work which, like washing: 
and ironing, causes great and continued action of the abdominal muscles, 
should be avoided. Such exercise is highly injurious, and is apt to pro- 
duce premature labor. Exercise in the open air, on foot, or by an easy 
conveyance, conduces to the health of the mother and the growth and 
development of the foetus. On the other hand, rnpid riding over rough 
roads is one of the most dangerous modes of exercise. It has been known 
to destroy the foetus, which up to that time had been apparently vigorous. 
When such a result occurs, there is probably more or less detachment of 
the placenta. 

It being a matter of the utmost importance that the health of the 
mother should continue good during gestation, any disease which she may 
have in this period, and which affects her nutrition or the character of her 
blood, should be promptly cured if practicable, and with the least possi- 
ble reduction of the vital powers. Intermittent fever, occurring during 
gestation, should never be allowed to continue. It seriously retards fcetal 
development, and may produce miscarriage. Unless it be controlled by 
proper measures, the offspring, though born at term, is puny and emaci- 
ated. Syphilis, in the pregnant woman, also requires treatment. This dis- 
ease, readily transmitted from the mother to the foetus through the ovum 
or the uterine circulation, may be eradicated by anti-syphilitic treatment 
of the mother, or at least so modified, that the infant is born vigorous and 
healthy. 

The pregnant woman should avoid all causes of undue mental excite- 
ment. This is almost as necessary as the avoidance of great physical 
exertion. There is, during pregnancy, unusual susceptibility to mental 
impressions, and this should be borne in mind not only by the woman her- 
self, but by those who associate with her. 

Strong emotions, whether of joy, sorrow, or anger, affect primarily the 
nervous system, but indirectly most of the organs of the body. Observa- 
tions have long established the fact that such emotions influence the state 
and functions not only of the digestive and glandular, but muscular organs, 
as the heart and uterus. Physicians are familiar with cases in which 
vivid mental impressions produced uterine contractions, and even miscar- 
riage, or have disturbed the catamenial function. Therefore, the associa- 
tions and cares of pregnant women should be such as conduce to cheei ful- 
ness and equanimity. 

It is the popular belief, and the belief of many physicians, that vivid 
mental impressions sometimes have a direct effect on "the development of 
the foetus. Many cases are on record in which infants were born with 
marks or deformities corresponding in character with objects which had 
been seen and had made a strong impression on the maternal mind at 
some period of gestation. Whether the mind of the mother exert a con- 



MATERNAL IMPRESSIONS. 21 

trolling influence on the form and color of the foetus, is a subject of great 
interest to the psychologist as well as the physiologist and physician, since it 
involves no less a question than the power and scope of the human mind. 
Violent emotions, it is admitted, may affect directly most of the impor- 
tant organs in the system. They may derange the liver, causing jaundice, 
accelerate, or for a moment suspend, the heart's action, stimulate the kid- 
neys, causing diuresis, or even the intestinal follicles, causing watery 
evacuations. But with all these organs the brain is connected by nerves 
which anatomy reveals. On the other hand, the mother and foetus have 
a distinct existence as regards their nervous systems, and even their blood. 
Still, the multitude of facts which have accumulated justify the belief that 
deformity, or other abnormal development of the foetus is, at times, due 
to the emotions of the mother. Some of the cases related by Dr. TVhite- 
head, in his work on hereditary diseases, are very striking and difficult to 
explain on the ground of coincidence. I have met the following cases. 
An Irish woman of strong emotions and superstitions was passing along a 
street in the first months of her gestation, when she was accosted by a 
beggar, who raised her hand, destitute of thumb and ringers, and in 
" God's name" asked for alms. The woman passed on ; but reflecting 
in whose name money was asked, felt that she had committed a great sin 
in refusing assistance. She returned to the place where she had met the 
beggar, and on different days, but never afterward saw her. Harassed by 
the thought of her imaginary sin, so that for weeks, according to her 
statement, she was made wretched by it, she approached her confinement. 
A female infant was born, otherwise perfect, but lacking the fingers and 
thumb of one hand. The deformed limb was on the same side, and it 
seemed to the mother to resemble precisely that of the beggar. In 
another case which I met, a very similar malformation was attributed by 
the mother of the child to an accident occurring to a near relative, which 
necessitated amputation during the time of her gestation. I examined 
both of these children with defective limbs, and have no doubt of the 
truthfulness of the parents. In May, 1868, I removed a supernumerary 
thumb from an infant, whose mother, a baker's wife, gave me the follow- 
ing history. No one of the family, and no ancestor, to her knowledge, 
presented this deformity. In the early months of her gestation she sold 
bread from the counter, and nearly every day a child with double thumb 
came in for a penny roll, presenting the penny between the thumb and 
the finger. After the third month she left the bakery, but the malforma- 
tion was so impressed upon her mind that she was not surprised to see it 
reproduced in her infant. 

Professor William A. Hammond, of this city, in an interesting paper 
on the "Influence of the Maternal Mind," etc. (Quarterly Journal of 
Psychological Medicine, January, 1868), says: "The chances of these 
instances, and others which I have mentioned, being due to coincidence, 



22 CARE OF THE MOTHER IN PREGNANCY. 

are infinitesimally small, and though I am careful not to reason upon the 
principle of post hoc, ergo propter hoc, I cannot, nor do I think any 
other person can, no matter how logical may be his mind, reason fairly 
against the connection of cause and effect in such cases. The correctness 
of the facts can only be questioned ; if these be accepted, the probabili- 
ties are thousands of millions to one that the relation between the phe- 
nomena is direct. " Professor Dalton also says {Human Physiology) : 
" There is now little room for doubt that various deformities and deficien- 
cies of the foetus, conformably to the popular belief, do really originate 
in certain cases from nervous impressions, such as disgust, fear, or anger, 
experienced by the mother." The observations on which this belief is 
based relate both to man and the lower animals. A very strong argument 
in its support is, as Professor Hammond remarks, the popular opinion, 
which dates back to the time of Jacob. (Genesis xxx.) An almost univer- 
sal sentiment, running through centuries, is rarely wholly fallacious. It 
has some truth for its foundation, especially when, as in this instance, 
the subject is one of observation. 

If maternal emotions affect the development of the exterior of the 
fcetus, as observations show, and physiologists admit, the presumption is 
strong that they may affect also the proper development and adjustment 
of the parts of the brain, an organ so complex and delicate, and may 
therefore give rise to idiocy. Dr. Seguin (Idiocy and its Treatment, etc., 
New York, 1866) thus remarks on this point : " Impressions will, some- 
times, reach the fcetus in its recess, cut off its legs or arms, or inflict 
large flesh wounds, before birth, . . . from which we surmise that 
idiocy holds unknown though certain relations to maternal impressions, as 
modifications to placental nutrition." 

It is an interesting fact that abnormalities of structure, occurring 
from whatever cause, are apt to be propagated to descendants. Dr. Car- 
penter and others relate instances among the lower animals, and similar 
instances of transmission have now and then been observed in the human 
race. Thus, in the issue of Nature for March 7th, 1878, it is stated on 
the authority of M. Lenglen, a physician of Arras, that a certain M. 
Gamelon in the last century had two thumbs on each hand, and two 
great toes on each foot ; this peculiarity did not appear in the son, but it 
reappeared in the three succeeding generations, so that some of the great- 
great-grandchildren possessed it in as marked a degree as their ancestors. 

In view of such important facts, the duty of the pregnant woman is 
rendered the more imperative to avoid the presence of disagreeable and 
unsightly objects, as well as all causes of excitement, and to remove, as 
soon as possible, vivid and unpleasant impressions, by quiet diversion of 
the mind. 

The disastrous results upon the fcetus of severe injuries received by the 
mother are well known to the profession, for premature labor and death 
of the child, or feebleness from its prematurity, are common results of 



MATERNAL INJURIES. 



23 




such accidents. In rare instances the child may be so injured as to be 
deformed for life, as in the following interesting case : Richard L., ao-ed 
six years, came, in January, 18*77, -.-, -. 

" x IG. 1. 

to the children's class in the 
Bureau for the relief of the Out- 
Door Poor. The following history 
was obtained : On November 27th, 
1870, one month before the birth 
of Richard, the mother fell heavily 
on the ice when stepping from a 
city car. Uterine hemorrhage re- 
sulted, which continued more or 
less freely, producing marked 
pallor, till her confinement, which 
occurred December 23d. The po- 
sition of the child in utero was 
crosswise, but nothing untoward 
occurred in the delivery. Imme- 
diately after its birth, when it was 
being washed by the nurse, a blister, 
about one inch in diameter, was 
observed on the right side of the 
thorax, located about one inch below 
and two and a half inches externally to the nipple. A cicatrix resulted 
which now marks the site of the sore. When the blister healed the child 
seemed entirely well, and nothing more was thought of the unusual occur- 
rence of an intra-utcrinc vesication, till nearly half a year had elapsed, when 
the thorax below the nipple and at the site of the cicatrix, was observed to 
be depressed, and the depression has continued to the extent indicated in 
the wood-cut. 

The ribs at the point of depression are found to be widely separated ; 
the rib below being pushed downward so as to form one side of the tri- 
angle, its cartilage the second side, and the rib above the hypothenuse. 
The distance of the perpendicular line passing from the costo-chondral 
articulation of the lower rib to the upper rib, or the hypothenuse, is two 
and a half inches by measurement. The depression in this triangular 
space evidently resulted gradually from the wide separation of the ribs, 
and the consequent loss of resiliency in the thoracic walls in the space 
destitute of bony support. The child lay crosswise in utero, and it seems 
probable that the injury was produced by the pressure of its arm against 
the ribs during the fall. Cases like the above, and the graver cases in 
which foetal life is sacrificed, or the child is born to a puny and uncertain 
existence from prematurity, show the very great importance of a quiet and 
regular life on the part of one who is about to become a mother ; for 
bodily injuries, like unpleasant sights, occur when least expected. 



24 MORTALITY OF EARLY LIFE. 



CHAPTER III. 

MORTALITY OF EARLY LIFE : ITS CAUSES AND PREVENTION. 

No fact is better known in the profession than that the first years of 
life constitute the period of greatest mortality. 

In England, where there is an accurate registration of births and deaths, 
statistics show fifteen deaths in every hundred infants in the first year of 
life, and between four and five deaths in the first month. Statistics on 
the continent correspond with those in England, as regards the periods of 
greatest mortality. ' Quetelet says :...." There die during the 
first month after birth, four times as many children as during the second 
month after birth, and almost as many during the entirety of the two 
years that follow the first year, although even then the mortality is high. 
The tables of mortality prove, in fact, that one tenth of children born die 
before the first month has been completed." 

In this country, in consequence of deficient registration of births, the 
percentage of deaths to births cannot be accurately ascertained. In this 
city, 53 per cent of the total number of deaths occur under the age of five 
vears, and 26 per cent under the age of one year. According to the 
census of 1865, there were in New York city 95,020 children under the 
age of five years, and during the five years ending with 1865, 49,000 
children five years old and under had died. Therefore, according to these 
statistics, more than one third of all the infants born in this city die under 
the age of five years. An error, however, occurs from the fact that, 
while the death statistics were complete, it is known there were more chil- 
dren in the city than were embraced in the census returns. Still it may, 
I think, be safely stated that one fourth of the children born in this city 
die before the age of five years. 

In less crowded cities and the rural districts, it is known that the per- 
centage of deaths in the first years of life to the total number of deaths 
is considerably less than in New York city, but it is nevertheless large. 

As the child advances toward puberty, the liability to sickness and 
death gradually diminishes, but even the last years of childhood present a 
considerably larger percentage of deaths to the population than does youth 
or manhood. 

The causes of this great mortality of infants and children, and the 
means of diminishing it, deserve careful consideration. 

Some of the causes which conspire to produce it are to a considerable 



CAUSES OF INFANTILE MORTALITY. 25 

extent unavoidable. Such are congenital vices of formation of internal 
organs. Many of the internal malformations necessarily occasion an early 
death. Cases of anencephalus, most cases of congenital hydrocephalus, 
of spina bifida, of cyanosis, are fatal before the close of infancy. These 
defects of formation we cannot detect before birth, and their causes aie 
often obscure. Some of them seem to result from inflammation, believed 
to be, occasionally, syphilitic, developed at some period of foetal exist- 
ence. Other internal malformations are attributable to perturbating influ- 
ences, operating temporarily on the mother during gestation. But in a 
large proportion of cases, we cannot assign the cause. Obviously, only 
partial success can attend our efforts, as regards prevention, in these cases, 
and almost no success, as regards the use of remedial measures. 

Another obvious cause of the great mortality of early life, is natural 
feebleness of system, especially in infancy. The younger the patient, 
prior to the middle period of life, the sooner are the vital powers ex- 
hausted by disease. Hence a larger proportion of infants succumb to the 
same malady, than children, and a larger proportion of children, than adults. 
This statement is true of infancy and childhood in general. It is a law 
in nature, and cannot be changed by art. But there arc many infants 
born with hereditary disease, or a strong predisposition to disease, through 
a fault, which is, in a degree, curable, in the system of one or both 
parents ; as, for example, the syphilitic, scrofulous or tubercular diathesis. 
Parents seriously affected by such diseases cannot, without corrective treat- 
ment, have healthy offspring. Their children are among the first to droop 
and die, either directly from the inherited disease, or from feebleness of 
constitution which such disease entails, and which renders them an easy 
prey to other diseases. The duty of the physician, as regards such 
parents, is obvious. He may, by therapeutic and hygienic measures, 
secure a more healthy progeny, and, so far as he can do this, he aids in 
diminishing the infantile mortality. He may sometimes, by timely 
measures directed to the infant, establish a better state of health. 

The subject of hereditary disease is one of great interest and impor- 
tance, especially as regards the city population. Inherited affections are 
less common in the country, but in the city they contribute largely to the 
number of deaths in early life. 

Another important cause of the great mortality of children, is the fact 
that they are peculiarly liable to certain severe and fatal maladies. I 
allude particularly to the acute infectious diseases, which, as a rule, occur 
but once, and that in childhood. Some of them, as scarlet fever, greatly 
increase the number of deaths. They extend and become epidemic 
through the intercourse of children. We are constantly witnessing in 
New York the spread of the acute contagious diseases, especially of 
whooping-cough, measles, scarlet fever, and diphtheria, through the 
schools. Measures employed, thus far, by boards of health, or other local 



26 MORTALITY OF EARLY LIFE. 

authorities, to prevent the dissemination of these and kindred diseases, 
have been but partially successful except in regard to smallpox. In the 
large public schools especially, these maladies are most frequently con- 
tracted, and from them they radiate over the school districts. For if, 
as is now common, at least in New York city, a child comes to school 
wearing clothes which at home have lain in a room where a brother or 
sister was sick with measles or scarlet fever ; or if he enter the class with 
a mild pertussis or diphtheria, certain of his class-mates will probably re- 
turn home infected with the virus of the disease. The same remarks are 
applicable, though with less force, to private schools. From both such 
schools, I have over and over again witnessed the dissemination not only 
of the maladies mentioned, but also of the milder infectious diseases, as 
mumps and varicella. The Health Board of New York city have re- 
cently, by stringent enactments regulating the schools, accomplished much 
in suppressing this source of the infectious diseases. 

In hospitals and asylums for children, much can be done to prevent the 
occurrence of the infectious diseases by strict surveillance and prompt 
isolation of all suspicious cases. Without such care, scarcely a year 
passes in which these institutions are not scourged by one or more of 
these diseases. Much has been said of the crowding of families in tene- 
ment-houses, so common in New York and other large cities, by which a 
large number of children are brought under one roof ; of the uncleanliness 
of person and apartment to which it leads, and of the insufficient air and 
space which it allows to each. But one of the strongest objections, in 
my opinion, to the present plan of building and crowding tenement-houses 
is the facility which it affords to the spread of the contagious diseases of 
childhood ; and it is in such houses, as shown by statistics, that these 
maladies are the most frequent and fatal. The much-needed enactments 
or regulations in relation to the construction and occupancy of such 
houses, would, among other salutary effects, greatly diminish the death- 
rate from the infectious maladies. 

Over the most loathsome, and formerly the most fatal, malady of man- 
kind, namely, smallpox, we now have, or can have, complete control by 
statutory enactments enforcing vaccination. It is only by carelessness 
or the lack of sufficiently stringent regulations relating to the matter that 
smallpox is not " stamped out." Again, some of the most fatal inflam- 
matory diseases of life occur chiefly in childhood, as croup and capillary 
bronchitis. These and kindred diseases can only be prevented by proper 
hygienic management on the part of families, and the circulation of tracts, 
or other means calculated to educate families in reference to the manage- 
ment of children, cannot fail to diminish the number of cases of such in- 
flammations, and consequently of the deaths from them. 

Another obvious and important cause of the mortality of early life, is the 



LOCALITIES AND CLEANLINESS. 27 

anti-hygienic condition or state in which many children live, in conse- 
quence of the poverty or gross negligence of parents. 

Residence in insalubrious localities, personal and domiciliary uncleanli- 
ness, exposure without proper protection to vicissitudes of weather, are 
fertile causes of sickness and death. Hence one reason for the great in- 
fantile mortality among the city poor, who live in damp and dark alleys, 
and in crowded and filthy tenement-houses, breathing night and day an 
atmosphere loaded with noxious gases. All physicians are aware how the 
malignant diseases, such as Asiatic cholera, cholera infantum, diphtheria, 
and typhus fever, seek the quarters of the city poor, and what terrible 
havoc they make there. All are aware, also, what wonderful recoveries 
result, when feeble and attenuated infants, gradually sinking with chronic 
diseases, induced in great measure by this malaria, are transferred from 
such localities to the pure air of the country. 

Careless management of young children as regards dress increases 
greatly the liability to local diseases, such as commonly occur from ex- 
posure to cold. These are inflammatory affections, seated chiefly upon 
the mucous surfaces, but sometimes in parenchymatous organs. Adults, 
aware of the effect of sudden change of temperature from warm to cold, 
or of exposure to currents of air, protect themselves by additional cloth- 
ing. Such precautionary measures are often lacking in the management 
of young children, and hence one cause of their great liability to local 
affections, both of the respiratory and digestive organs. 

Routh, in his excellent treatise on Infant Feeding, says : " Among the 
most pernicious influences to young children, however, we may include 
cold ; the change of temperature from 45° to 4° or 5° below zero, as 
before stated, producing an increase of mortality in London alone of 
three to five hundred. As out of one hundred deaths, however, from all 
specified causes, nearly twenty-four occur to children under one, and 
thirty-six to children under five ; the great increase of mortality to chil- 
dren by cold is thus at once made obvious. Indeed, it is a household 
word among us, which takes its origin from the Registrar-General's re- 
turns, that a very cold week always increases the mortality of the very 
young and the very aged." 

Lastly, a very important cause of mortality in early life is the use of 
improper food. In infants, artificial feeding in place of the aliment which 
nature has provided for them, and, in children, the use of innutritious or 
indigestible articles of diet, give rise to diarrhceal maladies, emaciation, 
and death in numerous instances. Sometimes, also, defective alimentation 
is the cause of scrofulous or tuberculous ailments, and sometimes it gives 
rise to a cachexia or feebleness of system, which, without engendering 
any positive disease, renders those thus affected less able to support dis- 
ease induced by other causes. A committee, of which Professor Austin 
Flint, Jr., was chairman, appointed in 1867 to revise the " dietary table 



28 MORTALITY OF EARLY LIFE. 

of the Children's Nurseries on Randall's Island," states, with much truth 
and force : "Children . . . are not capable of resisting bad alimen- 
tation, either as regards quantity, quality, or variety. At that age the 
demands of the system for nourishment are in excess of the waste ; the 
extra quantity being required for growth and development. If the proper 
quantity and variety of food be not provided, full development cannot 
take place, and the children grow up, if they survive, into puny men and 
women, incapable of the ordinary amount of labor, and liable to diseases 
of various kinds. ' ' 

Improper feeding, like other causes of mortality, is much more injuri- 
ous, much more frequently the cause of death, in the city than in coun- 
try. Statistics in Europe, as well as this side of the Atlantic, establish 
this fact. It is in infancy, and especially in the first year, that the use of 
unwholesome food entails the most serious consequences. No artificially 
prepared food is a good substitute for the mother's milk, and hence arti- 
ficial feeding of the infant, unless under the most favorable circumstances, 
results disastrously. In the country, where salubrious air and sunlight 
conspire to invigorate the system, where a robust constitution is inherited, 
and where cow's milk, fresh and of the best quality, is readily obtained, 
lactation is not so necessary for the well-being of the infant ; but in the 
city, its importance cannot be too strongly urged. 

The foundlings of the cities afford the most striking and convincing 
proofs of the advantages of lactation. In some cities foundlings are wet- 
nursed, while in others they are dry-nursed, and the result is always 
greatly in favor of the former. Thus, on the continent, in Lyons and 
Parthenay, where foundlings are wet-nursed almost from the time that 
they are received, the deaths are 33.7 and 35 per cent. On the other 
hand, in Paris, Rheims, and Aix, where the foundlings were wholly dry- 
nursed, at the date of the statistics their deaths were 50.3, 63.9, and 80 
per cent. 

In this city the foundlings, amounting to several hundred a year, were 
formerly dry-nursed ; and, incredible as it may appear, their mortality 
with this mode of alimentation, nearly reached 100 per cent. Now wet- 
nurses are employed for a portion of the foundlings, with a much more 
favorable result. 

These facts, to which others might be added from the experience of 
European cities, show the importance of lactation as a means of reducing 
infantile mortality in the cities. What has been stated as regards the 
result of artificial feeding of foundlings, is true, in great measure, in ref- 
erence to all city infants. The ill effect of artificial feeding is well known 
in this city, and it is the common practice in families to employ a hired 
wet-nurse, if, for any reason, the mother's milk is insufficient. 

When the infant has reached the age at which it is proper to wean it, 
the digestive organs are less frequently deranged by errors of diet. More 



WEIGHT, G K O W T H . LACTATION. 29 

substantial food, and considerable variety in it, may now be not only safely 
allowed, but are required by the wants of the system. Still, the feeding 
of children in health, and much more in sickness, is a subject of great im- 
portance. Therefore lactation, and the diet of infancy and childhood, 
will occupy our attention in the following pages. 



CIIAPTEE IV. 

WEIGHT, GEOWTH, LACTATION. 

Dr. Kate Parker, resident physician of the X. Y. Infant Asylum, 
weighed immediately after birth 1*70 infants, 89 male and 81 female, born 
consecutively, and at term, with the following result : 

Average male weight ....... 7 lbs. 11 oz. 

" female " ...... 7 lbs. 4 oz. 

Fifty of these, who were wet-nursed, and apparently well taken care of, 
were weighed when one week old, with the following result : 

Increase of weight in ....... 32 cases. 

Loss of weight in . . . . . . . . 13 " 

Average gain 4-, 8 - oz. 

" loss 3^ oz. 

Greatest gain 12 oz. 

" loss ...... . . 6 oz. 

AVERAGE GAIN. 

From hirth to age of 3 months (25 cases) . . .4 lbs. 8| oz. 
" 3 to G mouths (6 cases) .... 3 lbs. 3^ oz. 

" C to 9 " " 2 lbs. 7£ oz. 

•' 9 to 12 " " llb.l5£oz. 

It is desirable that the infant, as soon as it requires nutriment, should 
receive breast-milk. If it be fed, for a few days, with the bottle or spoon, 
it may be difficult finally to induce it to take the breast ; therefore it is 
well to determine early whether the mother will be able to wet-nurse her 
infant, so that, if unable, suitable provision may be made. 

The matter of determining, beforehand, the capability of the mother 
for wet-nursing has been investigated by Dr. Donne, of Paris, and in his 
treatise on Mothers and Infants he describes the mode in which it mav be 
ascertained. The desired information, in his opinion, may be acquired 
by examining the colostrum, which is secreted in small quantity, in the 
last months of gestation, and which can be squeezed from the breast in 
sufficient quantity for inspection. 



30 WEIGHT, GROWTH, LACTATION. 

In some women, according to Dr. Donne, the colostrum is so scanty 
that only a drop, or half a drop, can be obtained from the nipple by care- 
ful pressure. This will be found by the microscope to contain but few 
milk-globules, ill-formed, and a few granular bodies, such as the colostrum 
ordinarily contains. Such women almost invariably furnish poor milk, 
and in small quantity. In other women the colostrum is abundant but 
thin, resembling gum-water ; it lacks the yellow streaks and viscous char- 
acter of ordinary colostrum, and it flows readily from the nipple. The 
milk of such women is sometimes scanty, sometimes abundant, but it is 
watery and deficient in nutritive principles. In a third class of women, 
the colostrum is pretty abundant, and it contains yellowish streaks, of 
more or less consistence, which are found to be rich in milk-globules of 
good size. Women furnishing such colostrum in the last weeks of gesta- 
tion will have sufficient milk and of good quality. These latter women 
make the best wet-nurses. 



Hindrances to Lactation and Physical Conditions rendering it Improper. 

The primipara often experiences difficulty in wet-nursing in conse- 
quence of a depressed state of the nipple. It is not sufficiently promi- 
nent to be readily grasped by the mouth, and after ineffectual attempts, 
the infant becomes fretful when applied to the breast, and perhaps for a 
time refuses it altogether. Multiparas occasionally experience the same 
inconvenience, but it is not common when there has once been successful 
lactation. By calmness and perseverance on the part of the mother, the 
nursling can usually be made to seize the nipple in the course of a week. 

Depression of the nipple is, to a certain extent, the result of pressure 
upon it by the dress during gestation. The state of the nipples should, 
indeed, in those who have never suckled, receive early attention, even 
before the birth of the infant. Tightness of dress around the breast, as 
also upon every part of the body, should be avoided, and from time to 
time gentle traction should be made upon the nipple, if it be depressed. 
It may be drawn out by the fingers of the mother several times each day, 
or by a common breast-pump, or by suction with a tobacco pipe, the edge 
of the bowl having been smoothed. Occasionally, in these cases of de- 
pressed nipple, the mother, fatigued and discouraged by her frequent 
ineffectual attempts to induce the infant to nurse, becomes feverish and 
excited, so that the quantity of her milk is sensibly diminished. The 
physician should assure her, as he usually can with confidence, that in a 
few days, as the baby becomes a little stronger, there will be no difficulty 
in its nursing. Some women are unremitting in their endeavors to procure 
nursing. This should be forbidden, since the lack of sleep, and the 
nervousness which such constant endeavor produces, tend to defeat the 
object which they have in view, by diminishing the secretion of milk. 



HINDRANCES TO LACTATION. 31 

Sufficient sleep, freedom from anxiety, and no more frequent application 
of the infant to the breast than is required in successful lactation should 
be enjoined. Occasionally we can best succeed in procuring lactation 
under these circumstances of discouragement by the aid of another 
infant, older, more vigorous, and better able to seize the nipple. An ex- 
change of infants for a few times may remedy the difficulty. 

Occasionally suckling is rendered difficult and painful by too long delay 
before applying the infant to the breast. When the mother has rested 
a few hours after her confinement, about six in ordinary cases, lactation 
may commence. There is, at first, but very little milk, often only a few 
drops, but the secretion is promoted by nursing, so that the requisite 
amount is sooner obtained than when the infant is kept from the breast 
till the second or third day. If. as some physicians advise, suckling is 
deferred till the breasts are full and tender, and if, as is often the case 
with primiparse, the nipples are also tender, many mothers lack the forti- 
tude required to allow their infants to obtain a sufficient amount of milk. 
Excoriated and fissured nipples constitute a serious impediment to lacta- 
tion. They are very sensitive on pressure, and are long in healing. 
They are fully described in works which relate to female diseases, and 
their treatment pointed out. Occasionally fissured nipples do harm to 
the infant by the blood which escapes and is swallowed with the milk. 
A case is related in which positive indigestion was caused in this way ; 
the infant vomiting, after each nursing, milk mixed with blood. The 
local hindrances to lactation described above can, in most instances, be 
relieved in the course of a few weeks. To what extent menstruation and 
pregnancy are detrimental to the nursing, and therefore contra-indicate 
lactation, will be considered in another section. 

There is, occasionally, a constitutional state of the mother which neces- 
sitates either the employment of a hired wet-nurse or weaning. This is 
the case when there is a strong tendency to tuberculosis. If the com- 
plexion be pallid, the system at all emaciated, and suckling be attended 
by more or less exhaustion, and if with fair trial of wine and tonics no 
improvement follow, the physician is justified in forbidding farther attempts 
at wet-nursing. If, under such circumstances, an hereditary tendency to 
tuberculosis exist, it is his duty to positively interdict nursing. The 
opinion of the physician, in such a matter, should be formed after mature 
deliberation. There are many women who, suffering temporarily from 
illness, and discouraged, are ready at once to abandon their infants 
to the care of others, with the least encouragement on the part of the 
physician to do so, but who, by attention to their own health, and especi- 
ally by taking more sleep, soon recover from their depression, and become 
good wet-nnrses. On the other hand, night-sweats, a cough, and pro- 
gressive decline in health, show the need of immediate suspension of wet- 
nursing. 



32 WEIGHT, GROWTH, LACTATION. 

Sometimes women, prior to pregnancy, present indubitable evidence of 
tuberculosis, but by the improved general health which attends pregnancy, 
the disease is temporarily arrested. Such women should never suckle 
their infants. If they do, they soon lose all that was gained, and the 
disease advances rapidly. These objections to wet-nursing in such a state 
of health apply to the mother. There are also objections as regards the 
infant. The milk of those in decidedly infirm health, is deficient in 
nutritive principles. Their infants, therefore, are ill-nourished, and, if 
they have inherited a predisposition to tuberculosis, there is great danger 
that this disease will be developed in them ; whereas with healthy wet- 
nursing, even a strong predisposition may remain latent. M. Donne 
relates the following instructive cases, which show the danger which 
sometimes attends suckling, and the imperative necessity which may arise 
of discontinuing it. " A very light-complexioned young mother, in very 
good health, and of a good constitution, though somewhat delicate, was 
nursing for the third time, and, as regarded the child, successfully. All at 
once this young woman experienced a feeling of exhaustion. Her skin 
became constantly hot ; there were cough, oppression, night-sweats ; her 
strength visibly declined, and in less than a fortnight she presented the 
ordinary symptoms of consumption. The nursing was immediately 
abandoned, and from the moment the secretion of milk had ceased, all 
the troubles disappeared. " " A woman of forty years of age . 
having lost, one after another, several children, all of whom she had put 
out to nurse, determined to nurse the last one herself. . . . This 
woman, being vigorous and well built, was eager for the work and, rilled 
with devotion and spirit, she gave herself up to the nursing of her child 
with a sort of fury. At nine months she still nursed him from fifteen to 
twenty times a day. Having become extremely emaciated, she fell all at 
once into a state of weakness, from which nothing could raise her, and 
two days after the poor woman died of exhaustion." 

A very similar case recently occurred in my practice. A young and 
healthy woman from the country, suckling ber second infant, on coming 
to the city, lived in a dark and very imperfectly-ventilated room on the 
first floor, and in the rear of a crowded tenement house. She soon lost 
her appetite, but continued suckling for three months, when she became 
so anaemic and feeble that she was compelled to seek medical advice. She 
died without local disease, notwithstanding the most nutritious diet and 
the free use of stimulants and tonics. 

Constitutional syphilis in the mother does not contra-indicate lactation. 
It is probable that the infant also has it. The mother should take anti- 
syphilitic remedies, which will eradicate the disease in herself, and also, 
if it be present, in the infant. Febrile affections, also, do not in general 
contra-indicate lactation. They may, however, for a time, diminish the 
quantity of milk or impair its quality. If, however, the mother be in a 



HINDRANCES TO LACTATION. 33 

critical state, or much reduced, whatever the disease, suckling should 
cease. Whether or not the infant should be taken from the breast, if the 
mother be suffering from one of the essential fevers, depends on the 
severity of the malady, and the degree of her exhaustion. Twice I have 
known newly-born infants to be suckled by mothers, while the latter had 
scarlet fever, without contracting it, but suffering immediately afterward 
from severe and protracted eczema. In the country, where artificially fed 
infants as a rule do well, it might be best to wean if the mother be affected 
with such a disease, but in the city eczema is less dangerous than the 
diarrhoeal affections which early weaning is apt to entail. In most cases 
of typhus and typhoid fevers, weaning or procuring a wet-nurse is neces- 
sary, on account of the depression of the vital powers which these diseases 
produce. 

Inflammatory affections, unless of a dangerous character, do not ordi- 
narily interfere with lactation, except that the quantity of milk be 
somewhat diminished. In severe inflammation, it may be so necessary 
to husband the strength, or to keep the patient perfectly quiet, that 
suckling her infant would be injudicious. It should then be transferred 
to a wet-nurse or weaned. Inflammation of the breast often presents an 
impediment to lactation. It is a common and painful affection, suspend- 
ing, or greatly diminishing the secretion of milk in the affected gland. 
Nursinof should cease as soon as there are evident sijins of inflammation, 
unless it be limited to a small part of the gland. General heat of the 
breast, with tenderness and induration extending over a considerable part 
of it, indicate the need of the immediate removal of the infant from it. 
Lactation must be restricted to the unaffected side. It is often the case 
that the volume of the inflamed gland is considerably increased from the 
afflux of blood to it, and from the interstitial exudation, while it contains 
little or no milk, and attempts at lactation, under such circumstances, are 
injurious to the mother as well as to the infant. The cause of the swell- 
ing should be explained to the mother, who commonly attributes it to the 
accumulation of milk, and worries herself and the infant, by attempts to 
make it nurse. As the inflammation abates, by resolution, or more com- 
monly by suppuration, and the normal secretion returns, the first milk, 
which is apt to be thick and stringy, should be rejected, after which the 
infant may nurse as usual. Occasionally, the abscess which has formed 
in the breast connects with a lactiferous tube, so that pus may, on suction, 
escape from the nipple. If this occur, of course lactation should be in- 
terdicted until pure milk is obtained. Pus in the milk can sometimes be 
detected by the naked eye. It presents a yellowish or greenish color, 
occurring in streaks, when not intimately mixed with the milk. When 
it is intimately mixed, and in small quantity, it cannot be detected by the 
naked eye, but the microscope reveals the pus-globules. M. Donne 
relates a case in which he discovered these globules by the microscope,. 



34 WEIGHT, GROWTH, LACTATION. 

although there were at first no other evidences of an abscess, and doubts 
were expressed in reference to the accuracy of his observation. Finally, 
an abscess pointed and discharged. 

Sometimes, when the inflammation abates, the secretion does not re- 
turn, and, worse still, occasionally the inflammation has occurred so near 
the nipple that the lactiferous tubes are permanently closed by it, so that, 
though milk form in the breast, there is no escape for it. Thenceforth 
lactation must be entirely from one breast. 

If erysipelas occur in the mother, the infant should be immediately 
taken from her breast and from her arms. If this disease should not be 
communicated to the infant through the milk, or through fissures in the 
nipple, of which there is danger, still the milk is apt to undergo such 
change in consequence of the erysipelas as to endanger the health of the 
child. Thus, one of the wet-nurses in the New York Infant Asylum 
sickened with severe facial erysipelas on the 24th of April, 1875, eight 
days after the death of her baby. She was wet-nursing a foundling, aged 
seven weeks, at the time of the commencement of the erysipelas, and as 
it was very important that her milk should be preserved for the coming 
hot months, it was deemed best to allow the nursing to continue, the 
infant being placed in a crib at a little distance as soon as it dropped the 
nipple. On the 27th, diarrhoea commenced in the baby. April 28th, its 
morning temperature was 101°, and that of the evening 103°, the diarrhoea 
continuing. It was now removed entirely from the breast, and was given 
artificial food. On the 29th there was a decided general icteric hue of 
the infant's surface, which continued till its death on May 1st. The 
stools numbered about eight daily till April 30th, when they ceased. The 
record which I preserved does not state whether there was vomiting, but 
it had probably been slight on account of the speedy prostration. Death 
occurred from exhaustion. At the autopsy, from half an ounce to one 
ounce of pus was found in the peritoneal cavity, newly formed fibrin was 
observed upon the spleen and liver, and the peritoneum generally had lost 
much of its lustre ; a careful microscopic examination of the liver and its 
ducts, made by Dr. Heitzmann, revealed no anatomical change which 
would explain the icteric hue, and it seemed probable that this was due 
to the altered state of the blood. The mucous membrane of the intestines 
exhibited vascular streaks, and its follicles were distinct. The lesions 
therefore indicated intestinal catarrh. Nothing unusual was observed in 
the heart and lungs of the infant. Its life had apparently been sacrificed 
by the unhealthy nursing. 

Colostrum. 

The milk secreted during gestation, and immediately after the birth of 
the infant, differs in its gross appearance, as well as chemical and micro- 
scopical characters, from that which is ordinarily secreted during lactation. 



COLOSTRUM. 



35 



It is termed Colostrum. It has a turbid and yellowish appearance, and 
is somewhat viscid. It is decidedly alkaline, and undergoes lactic-acid 
fermentation more readily than common milk, and it also contains more 
solid matter. It has an excess of fat, of salts, and, according to Simon, 
also of sugar. It appears, from Simon's analysis, that the solid matter of 
colostrum is about seventeen per cent, while that of the ordinary breast- 
milk is about eleven per cent. 

Examined by the microscope, the colostrum is seen to contain oil- 
globules and a viscid substance, which often assumes an ovoid or globular 
form, but which also exists in irregular masses of considerable size. This 
substance has been thought by some to be mucus, but it is dissolved by 
acetic acid and potash, and is tinged yellow by a watery solution of iodine. 
It is, therefore, to be regarded as albuminous. Imbedded in this substance 
are oil-globules, which are for the most part of small size, while the free 



Fig. 2. 



o ° 



* 05 






Milk-ijlobiiles. 




Colostrum-corpuscles 



oil-globules of colostrum are larger than those occurring in healthy milk. 
This viscid substance, with the imprisoned oil-globules, constitutes what 
has been designated the " colostrum-corpuscles." Some have erroneously 
considered the " colostrum-corpuscles" to be compound granular cells. 
The compound granular cell, or corpuscle, is a cell which has undergone 
fatty degeneration. It is distended with oil-globules to perhaps twice or 
thrice its normal size. On the other hand, examination of the "colos- 
trum-corpuscles" fails to detect a cell-wall, and the large and irregular 
size of some of these corpuscles negatives the idea that they are cells. 
The oil-globules contained in the viscid substance are more readily acted 
on by ether than are the free oil-globules. 

The colostrum is replaced by milk of the normal character in six to 
eight days : sometimes as early as the third or fourth day after delivery. 
In exceptional instances, the colostrum does not disappear for several 
weeks, and it may reappear at any time during lactation, as a consequence 
of derangement of the system, or from disease. It is assimilated with 
difficulty by the digestive organs of the infant, producing usually a laxa- 
tive effect. It, therefore, aids in the removal of the meconium, and being 



S6 

a normal secretion in the first week of Jactation, it is to be regarded as 
beneficial. Continuing longer than the first week, its effect is deleterious. 
It produces evident derangement of the digestive organs, and the infant 
that habitually nurses it never thrives. It has diarrhoea or vomiting, be- 
comes more or less emaciated, and suffers from colicky pains. Sometimes 
an extreme degree of exhaustion is reached before the cause is suspected, 
for, if the milk be pretty abundant, the admixture of colostrum with it 
cannot be detected by the naked eye. The microscope alone reveals it. 
The following is an interesting example of this fact. In 1868, an infant 
six weeks old was brought to me, with the following history : The 
mother had for several years been troubled with dyspeptic symp- 
toms, but had otherwise been in good health. The infant at birth was 
fleshy and strong, but after the first week it had never thriven like other 
infants. It nursed regularly, and the quantity of milk was apparently 
sufficient, but it vomited as soon as it ceased nursing, it was much 
emaciated, and the bowels were habitually constipated. The digestive 
organs of the infant had been in this unhealthy state, with little variation, 
from the first week, and it was very evident, from the emaciation and 
exhaustion, that it must soon perish, unless some change were effected. 
The milk of the mother presented the usual appearance to the naked eye, 
but under the microscope, colostrum-corpuscles were observed. A wet- 
nurse was immediately obtained, and from that moment the gastrointes- 
tinal symptoms disappeared, with a rapid recovery. This case shows at 
once the evil effects of the colostrum, and the need of a microscopic 
examination of the milk whenever the nursling suffers from lactation. 

Human Milk. 

The specific gravity of human milk is about 1032. It has been care- 
fully analyzed by different chemists, with nearly the same result. The 
following table, prepared by MM. Vernois and Becquerel, gives the pro- 
portion of the various ingredients in 1000 parts : 

Water, 889.08 

Sugar, 43.64 

Casein and extractive, . . .... 39.24 

Butter, 26.66 

Salts (ash), 1-38 

1000.00 

Milk, being the sole food of early infancy, contains all the nutritive 
principles which are required for the growth and repair of the different 
tissues. The casein is an albuminous principle, the butter and sugar are 
combustible substances, and most of the salts which occur in the different 
tissues exist primarily in the milk. Phosphate of lime, phosphate of 
magnesium, phosphate of the peroxide of iron, chloride of potassium, 



MODIFICATION OF THE MILK BY THE DIET. 37 

and chloride of sodium, known to exist in cow's milk, are believed to occur 
also in human milk. Epithelial cells are sometimes present, derived 
from the lining membrane of the lactiferous tubes. 

Modification of the Milk in consequence of the Diet. 

Fresh milk should give an alkaline reaction, but in certain states of ill- 
health, or after the use of certain articles of food, the reaction is acid. 
Mothers are well aware of the ill effects, as regards the infant, which fol- 
low their use of indigestible or acescent food ; and, if prudent, they, 
avoid it. The milk, if the diet of the mother be improper, may become 
so strongly acid as to cause colicky pains and diarrhoea. The following 
observations in reference to cow's milk are instructive. We may infer 
from them that the regimen of the mother exerts a decided influence on 
the alkalinity of her milk. According to Routh {Infant Feeding, page 
285), stall-fed cows almost always give acid milk. Dr. Mayer, of Berlin,, 
examined the milk from a considerable number of cows, with the follow- 
ing result : — 

(a.) Of cows fed with brewers' lees, red potatoes, rye bran, and wild 
hay, in five instances the milk was slightly acid ; in one very much so. 

(b.) Of forty cows fed with potato mash, barley husk, and clover and 
barley straw, in ten, which were examined, the milk was acid ; in three, 
very acid. 

(c.) From among fifty cows fed on potato mash, barley husks, and 
wild hay, five were examined, and in all the fresh milk was acid. 

(df.) From forty-two cows fed on potato mash, husks, wild hay, and 
rye straw, out of twelve selected for examination, the fresh milk of all 
was acid. 

(e.) From six cows fed by a chief gardener on coarse beet-root, red 
potatoes, bran mash, and hay, the fresh milk was slightly acid. 

(f.) From five cows fed by a cow-feeder on lukewarm bran mash and 
hay, in four the fresh milk was quite neutral, in one it was decidedly 
alkaline. {Routh.) 

The above observations of Dr. Mayer were made in the winter season, 
and it is possible that the acidity may have been partly due to the con- 
finement of the cows in stalls. But that it was mainly due to the food 
is evident from the fact that it was greater with some kinds of food than 
others. Cows' milk is not as alkaline as human milk, and is therefore 
more readily rendered acid. Still, what Dr. Mayer observed in reference 
to the cow exemplified a fact of general applicability, namely, that cer- 
tain kinds of food may affect the alkalinity of the milk, whether human 
milk or that of animals. 

The relative proportion of the different ingredients of the milk varies 
according to the diet. If the diet be poor, the amount of water increases, 



38 WEIGHT, GROWTH, LACTATION. 

and that of butter and casein diminishes. Lehmann says (Phys. Chemis- 
try, vol. ii., p. 65) : " From experiments made on bitches, it would 
appear that a vegetable diet renders the milk richer in butter and suo-ar ; 
while the solid constituents are augmented when a sufficient quantity of 
mixed food is given. Peligot found the milk of an ass most rich in 
casein when the animal had been fed on beet-root ; while it was richest 
in butter when the food had consisted of oats and lucerne. Fat food 
increases the quantity of the butter. Boussingault found the milk of a 
cow richer in casein when the animal had been fed on potatoes than when 
other food was taken. Reiset found that the milk of cows which were at 
grass was much richer in butter than when the animals had stood all night 
in their stall without food ; but Playfair found, on the contrary, that the 
quantity of butter in the milk increased during the night as much as dur- 
ing their stall-feeding, but that the quantity of butter in the milk was 
considerably diminished by the motion of the animals in the fields." * 
Simon made the following analyses of the milk of a poor woman. She 
was suddenly, during the period of lactation, deprived of the means of 
support, so that her food was insufficient in quantity, and of poor quality. 
The amount of her milk was not diminished by privation, but the solid 
constituents were reduced to 86 parts in 1000. After this, for a time 
her diet was nutritious and abundant, the quantity of milk was increased, 
and the solid constituents amounted to 119 parts in 1000. Her diet was 
again reduced, with a reduction of the solid elements to 98 in 1000, and, 
at a later period, the diet was again nutritious, with an increase of the 
solid elements to 126, The chief variation observed in the milk of this 
woman was in the amount of butter. 

Modification of Milk from its Retention in the Breast. 

M. Peligot has clearly demonstrated that the longer milk is retained in 
the breast the more watery it becomes. This is explained on the sup- 
position that the solid portion is first absorbed. Therefore, the milk is 
richer the more frequently it is removed from the breast. A similar 
fact, which has the same explanation, has long been known, namely, that 
the first milk taken from the breast is thinnest, while that which flows 
last is richest. That first removed has remained longest in the gland, 
while that which comes last is but recently secreted. 

A knowledge of this fact is of considerable practical importance. The 
milk, as M. Donne has shown, maybe too rich, so as to cause indigestion, 
with more or less enteralgia, in the infant. Some nurslings, if the milk 
be too rich and abundant, reject a part of it by vomiting, but others do 
not, and suffer the consequence in derangement of the digestive organs. 
For such cases the remedy is, to give the breast less frequently, by which 

* Animal Chem., Sydenham Soc.'s Trans., vol. ii., p. 55. 



MODIFICATION OF MILK BY CATAMENIA. 39 

a less amount of milk is taken, and milk of a poorer quality. On the 
other hand, if there be poverty of the milk, and the infant be insufficiently 
nourished, the milk is more nutritious, if the nursing be at short intervals. 

Modification of Milk by Age and by Mental Impressions. 

The composition of the milk varies, also, according to the age of the 
infant. Simon analyzed the milk of a woman at intervals for the period 
of about six months. In this case the amount of casein at first was 
small, but the quantity increased during the two months succeeding de- 
livery, after which it was nearly stationary. A similar increase was 
observed in reference to the saline substances. The sugar, on the other 
hand, diminished in quantity as the infant grew older, its maximum 
amount being in the first and second months. The quantity of butter in 
the milk varies from day to day more than the other elements. 

Many observations have been published which show that the composi- 
tion of the milk may be materially changed by mental impressions. The 
infant has died suddenly in the act of nursing, after his mother had been 
violently excited. Such a case is related by Tourtnal. The infant 
ceased nursing, gasped, and died in the mother's lap. In other cases 
convulsions have occurred. MM. Becquerel and Vernois made the chemi- 
cal analysis of the milk of a woman in a state of nervous excitement, and 
found that the solid constituents were diminished to 91 parts in 1000, 
the most marked diminution being in the butter, which was only about 
5 parts. In a case related by Parmentier and Deyeux the milk became 
watery and viscid, and remained so till the nervous attacks, from which 
the patient suffered, had ceased. Dairymen are well aware how ill- 
treatment and the separation of the calf from the cow diminishes the 
milk which she yields. A new milkman seldom obtains as much milk as 
one with whom the cow is familiar. Bouchut, alluding to the influence 
of the moral affections on the secretion of milk, makes the following re- 
mark, the truth of which most mothers will acknowledge : " It is also a 
fact, that the sight of the nursling, the idea of seeing it at the breast, 
and the joy which certain mothers thence experience, exercise a moral 
influence over the secretion of the milk entirely independent of their 
will. They feel the draught of milk as soon as they behold their child, 
or think of it too deeply ; and in a woman who saw her child fall to the 
ground, the flow of milk ceased, and did not reappear until the child, 
having quite recovered, attempted to take the breast." 

Modification of Milk by the Catamenial Function and Pregnancy. 

The catamenia reappear in most women before the close of lactation, 
often by the fifth or sixth month after delivery. If this function be re- 
established in the normal manner, that is, without any derangement of 



40 WEIGHT, GROWTH, LACTATION. 

the system, without pain or undue profnseness, no unfavorable result 
ordinarily occurs with the infant. On the other hand, if the mother 
suffer any disturbance of the system, or if the menses arc profuse, the 
lacteal secretion may be so changed that the infant is injuriously affected 
by it. The symptoms produced are those of indigestion, such as abdom- 
inal pains, more or less vomiting, and diarrhoea. This result is, how- 
ever, in my experience, quite exceptional. In rare instances, more dan- 
gerous symptoms occur in the infant. A case has been reported to me 
in which, at each catamenial period, the nursling was seized with convul- 
sions. 

Charles March and found in three chemical analyses of the milk during 
menstruation, a diminution of two to four parts in the butter, of two to 
five parts in the sugar, and a diminution in the casein and albumen of 
two to five parts. This seems but a trifling change when we recollect 
that human milk in the state of health contains, according to the analysis 
of M. Robin and others, 25 to 37 parts of butter, 37 to 49 parts of sugar, 
and 29 to 39 parts of casein, in 1000 of milk. If the menses reappear 
with regularity, when the infant has attained the age of ten or twelve 
months, they should be considered as designed to supersede the secretion 
of milk, which, indeed, usually begins to diminish. Weaning is then 
proper. If the menses return early in the period of lactation, and give 
rise to symptoms in the infant in consequence of the altered quality of 
the milk, it is advisable to allow but little nursing during the catamenia, 
and to employ artificial feeding instead, till the flow of blood ceases. 

The change produced in the milk by pregnancy is, in general, more in- 
jurious to the nursling than that caused by the reappearance of the 
menses. The milk of the pregnant woman is apt to contain more or less 
of that viscid substance which characterizes colostrum. Still, the milk 
of pregnancy does not, ordinarily, derange the digestive function as much 
as colostrum, in the first weeks of lactation, for pregnancy rarely occurs 
till after the infant is five or six months old, when the organs of digestion 
are less readily disturbed. The injurious effect of pregnancy on the 
infant is shown by vomiting or diarrhoea, by restlessness and occasional 
abdominal pains, in fine, by symptoms cf indigestion. In many cases, 
however, these symptoms do not occur, and the infant, though nursing 
regularly, continues to thrive. No doubt, as a rule, the nursling should be 
weaned when there are clear evidences of pregnancy, but under certain 
circumstances, weaning is injudicious. I have, on different occasions, been 
called to infants, in midsummer, dangerously sick with diarrhoeal attacks 
induced by this cause. These infants were, perhaps, doing well, or 
suffering but little from indigestion, when the mothers, suspecting them- 
selves pregnant, at once withdrew them from the breast, and cholera 
infantum or a kindred disease was the result. No infant in the city 
should be weaned in the hot months. It is much safer, though there 



DIFFERENCES IN SUCKLING WOMEN. 41 

be indubitable signs of pregnancy, that it continue nursing till the cold 
weather. The better method is, however, under such circumstances, to 
employ a wet-nurse, or to remove the infant to the country, and wean it 
there. In cold weather, it is usually safe to wean an infant in the city 
after it has reached the age of five or six months. 

The milk frequently contains other ingredients in addition to those 
which have been mentioned. Thus a large number of medicinal sub- 
stances, taken by the mother, may enter the milk, so as to produce their 
characteristic effect on the infant. It is a well-known fact, that the 
peculiar flavor of certain vegetables, taken as food, may be noticed in the 
milk. It is admitted, also, that the specific virus of the contagious dis- 
eases, at least certain of them, may enter the milk, so as to give rise to the 
same diseases in the infant. 

Differences in Suckling Women as regards Quantity and Quality of Milk. 

There is, however, a great difference, in different women, as regards 
the quantity and quality of their milk, and even the mode in which it is 
secreted. The best wet-nurses are usually robust without being corpu- 
lent. Their appetite is good, and their breasts are distended from the 
number and large size of the bloodvessels and milk-ducts. There is but 
a moderate amount of fat around the gland, and tortuous veins arc ob- 
served passing over it. Such nurses do not experience a feeling of ex- 
haustion and do not suffer from lactation. 

The nutriment which they consume is equally expended in their own 
sustenance and the supply of milk. There are other good wet-nurses who 
have the physical condition which I have described, but whose breasts are 
small. Still, the infant continues to nurse till it is satisfied, and it 
thrives. The milk is of good quality, and it appears to be secreted, 
mainly, during the time of suckling. Other mothers evidently decline in 
health during the time of lactation. They furnish milk of good quality 
and in abundance, and their infants thrive, but it is at their own expense 
They themselves say, and with truth, that what they eat goes to milk. 
They become thinner and paler, arc perhaps troubled with palpitation, 
and are easily exhausted. They often find it necessary to wean before 
the end of the usual period of lactation. There is another class whose 
health is habitually poor, but who furnish the usual quantity of milk with- 
out the exhaustion experienced by the class which I have just described. 
The milk of these women is of poor quality. It is abundant, but watery. 
Their infants are pallid, having soft and flabby fibre. All these kinds of 
wet-nurses are met in practice. 

Occasionally, a considerable part of the milk is lost by oozing from the 
breast. This sometimes occurs in robust women, but is more frequently 
associated with weakness. It is then due to a relaxed state of the orifices 



42 WEIGHT, GKOWTH, LACTATION. 

of the milk-ducts. Galactorrhea, as the excessive secretion and flow of 
milk is designated, is said to be often associated with a menorrha^ic dia- 
thesis : that is, women whose menses have been profuse are apt to have 
too abundant a flow of milk, corresponding with the menorrhagia. It is 
said that galactorrhcea is also apt to occur in those who are subject to dis- 
charges from parts which sustain no immediate relation to the breast, as 
in cases of haemorrhoidal flux, diabetes insipidus, etc. Excitement, or 
irritation of the uterus or ovaries, may serve as an exciting cause of galac- 
torrhoea in those predisposed to it, and excessive suckling may have the 
same effect. 

Scantiness of Milk ; its Causes and Treatment. 

Though the amount of breast-milk which the infant requires is less 
than was estimated by Cumming, still insufficiency of this secretion is not 
uncommon, especially in the cities. According to the statistics of Drs. 
Merei and Whitehead, among healthy mothers there is insufficiency in 
16.5 per cent, while among mothers in feeble health the percentage is 
46.6. In treating of this subject in the following pages, reference is not 
had to those cases in which there is temporary diminution of milk from 
acute disease or other perturbating causes, but to those cases in which 
there is habitual scantiness. 

One cause of scanty secretion of milk is a life of privation or of daily 
work, which necessitates separation from the infant. Insufficient food 
may render the milk more watery, as has already been stated, or it may 
cause diminution in its quantity. The mother thus situated is pallid. 
She is subject to palpitation and attacks of faintness. Her condition, in- 
deed, is that of anosmia. Working women have scantiness of milk, not 
only in consequence of hardships, but also because they are usually sepa- 
rated for hours from their infants. Age is also a cause of scantiness of 
milk. Mothers at the age of forty years ordinarily furnish less milk than 
between twenty and thirty. Those who have not borne children till 
late in life, and whose mammary glands have therefore long been inact- 
ive, have less milk than those who commence bearing children at the 
usual period. 

Routh speaks of hyperemia as a cause of defective lactation. " This 
is a variety," says he, " which I have chiefly observed among hired wet- 
nurses, selected from the poorer classes, and admitted into wealthier 
families. . . . When feeding at the expense of a master or mistress, the 
amount they devour often surpasses all moderate imagination. They, in 
fact, gormandize. If in such instances a wet-nurse be given all she asks 
for, she will be found often to eat quite as much as any two men with 
large appetites ; and, as a result, she becomes gross, turgid, often covered 
with blotches or pimples, and generally too plethoric to fulfil the duties of 
her position. The plethora, as first induced, is of the sthenic variety, 



SCANTINESS OF MILK. 43 

but it soon assumes an asthenic character, and, as the immediate result, 
the breast no longer secretes its quantum of milk. There may be good 
milk secreted, but it is in small quantity, and this quantity diminishes 
daily. The breast may also enlarge, but it is from a deposition of fatty 
tissue in and about it, as in other parts of the body. The veins on the 
surface become less apparent, always a bad feature in a suckling breast, 
till finally the flow of milk ceases altogether." 

Atrophy of the breast from the employment of iodine, or from long 
disuse, is also a cause of insufficiency of milk. 

It is so necessary for the health and development of the infant that the 
milk should be in proper quantity as well as quality, that it is best in a 
work of this kind to consider the treatment of insufficient secretion, and, 
on the other hand, of excessive secretion and loss of milk, or galactor- 
rhea, and first of insufficient or scanty secretion. 

The most efficient mode of increasing the lacteal secretion is that which 
is also natural, namely, suction from the nipple. There are many cases 
on record in which this has produced the flow of milk in women who 
have never borne children, and even in men. Baudelocque mentions the 
case of a girl, eight years old, who suckled her brother for a month, and 
cases at the opposite extreme of life have been reported ; one of a woman 
of seventy years, who wet-nursed a grandchild twenty years after her last 
confinement. 

The following case, which was under my observation, is interesting in 
this connection : Lizzie S. was confined with her first child on May 30th, 
1876. When the baby was a few days old, and before she had left the 
bed, she had inflammatory symptoms which proved to be due to pelvic 
cellulitis. Its course was tedious ; her milk diminished, and its secretion 
soon ceased. On or about the first of August she began to sit up, and on 
August 11th she was admitted into the Sixty-first Street branch of the 
Infant Asylum, pale and wasted, but with returning appetite. She had 
had no mammary secretion for eleven weeks, and her breasts were small 
and flabby. She had two fistulous openings, one vaginal, and the other 
low down in the back, near the lower end of the sacrum or the coccyx. 
The baby was in a fair condition, having been suckled by other women. 
Experiences in this and other institutions show that infants having breast 
milk do far better and are much more apt to live than those without 
breast milk, and the mother was therefore advised by one of the managers 
— himself a physician — to suckle her baby, although there was not a drop 
of milk in her breast, and nursing had been suspended eleven weeks. To 
the surprise of the mother, and of the nurses in the house — to whom the 
procedure seemed very ridiculous — milk began to appear in a few r days. 
The mother left the institution October 8th ; but before her departure she 
was able to furnish, perhaps, two-thirds the quantity of milk which her 
infant required. This case affords practical illustration of the fact that 



44 WEIGHT, GROWTH, LACTATION. 

frequent nursing is the most efficient galactagogue. Mothers sometimes, 
having little breast milk, suckle their babies at long intervals, and finally, 
discouraged at the unproductive state of their breasts, resort to weaning, 
when, by patience and more frequent lactation, they might become good 
wet-nurses. In the cities, and during the summer season, in which breast 
milk is so much required, the history of cases like the above, and the 
more remarkable cases in w T hich men and grandparents have had secretion 
of milk and have suckled infants, should induce the physician to withhold 
his consent to premature weaning, which the disheartened mother is apt 
to suggest, unless indeed he perceive other reasons for weaning apart from 
scantiness of milk. 

Travellers among barbarous nations or tribes have often observed these 
cases of unnatural lactation. Humboldt saw a man, thirty-two years old, 
who gave the breast to his child for five months, and Captain Franklin, 
in the Arctic regions, met a similar case. Dr. Livingstone, in his African 
travels, says that he has examined several cases in which a grandchild has 
been suckled by a grandmother, and equally remarkable instances of lac- 
tation occur among the negroes of the Southern and Middle States. Pro- 
fessor Hall presented to his class in Baltimore, a male negro, fifty-five years 
old, who wet-nursed all the children of his mistress. In these cases of 
abnormal lactation, so far as we have accurate records of them, it is ascer- 
tained that the breasts were torpid, and even sometimes, as in old people, 
atrophied till the nursing commenced. Titillation, or pressing of the 
nipple, caused an afflux of blood to the gland, and developed its functional 
activity, so that milk was produced for the sustenance of the nursling. 
Therefore, in case of scanty secretion of milk, the mother may increase 
the quantity by applying the infant often to the breast. If, dissatisfied 
with the small amount of nutriment which it receives, it refuse to make 
the necessary suction, any other mode of gentle traction or pressure may - 
be employed in addition. The occasional employment of another infant, 
or a pup, milking the breast with the thumb and fingers, or the gentle 
suction of a breast-pump, aids in stimulating the secretion. One of the 
best breast-pumps kept in the shops is that to which the name The 
Mother's Blessing has been applied. Forcible rubbing or traction of the 
breast defeats the purpose for which it is employed. It produces too 
much irritation and tenderness. The best mode of stimulation is by nurs- 
ing, as it is the natural mode, and the moral effect of the infant at the 
breast aids in promoting the secretion. 

Another mode of increasing the functional activity of the mammary 
glands is by the electrical current. The fact is established by physio- 
logical experiments, that glandular organs can be made to secrete more 
actively by the stimulus of electricity, and, accordingly, this agent has 
been successfully employed to promote the secretion of milk. In Routh's 
Infant Feeding several cases are related which show the beneficial effects 



SCANTINESS OF MILK. 45 

of this agent (page 149 et seq.). Among them are six reported by Dr. 
Skinner, of Liverpool. In all these, one or two applications of the elec- 
trical current sufficed to restore the secretion. The following is Dr. 
Skinner's mode of employing this treatment : 

"1. Direct. — Both poles must terminate in cylinders, with sponges 
well moistened in tepid water. The positive pole is pressed deep into the 
axilla, while the negative is lightly applied to the nipple and the areola : 
the current being no stronger than is agreeable to the patient's feelings. 
The poles are kept in this position for about two minutes. 

"2. Intramammanj . — The poles are to be, as it were, imbedded in 
the mamma, and moved about, raising and depressing both poles at once 
in and around the organ for the space of another two minutes. The same 
is to be done to both breasts daily, until the secretion is properly estab- 
lished. Hitherto one or two sittings have always sufficed in my hands.'" 
(Communication of Dr. Skinner to Dr. Ronth.) 

In all cases of scanty secretion of milk, the regimen of the mother is a 
matter of importance. Personal and domiciliary cleanliness is essential 
for successful wet-nursing. A certain amount of exercise in the open air 
is conducive to the health of the mother, and to the secretion of abun- 
dant and healthy milk. A case is related to show the effect of fresh air 
and outdoor exercise on the lacteal secretion. A lady of cleanly habits, 
living in London, had a very scanty supply of milk. She removed to the 
pure air of the seashore, and immediately the quantity became abundant, 
and continued so for months, Such cases arc not infrequent. A mode 
of life that contributes to the general health of the mother will not fail to 
augment the quantity of her milk, if it be scanty, and to improve its 
quality. 

Much has been written in reference to the diet of women who suckle. 
It is a popular belief that certain articles of food promote the secretion 
of milk much more than other articles, though equally nutritious. Xo 
doubt, writers have erred in recommending exclusively this or that kind 
of food, as most likely to produce milk. The exact kind of food which 
is preferable, in a certain case, depends partly on the physique of the in- 
dividual, and partly on the character of the food to which she has been 
accustomed. A mixed diet contributes most to the sustenance of the 
mother, and to an abundant secretion of milk. Animal substances which 
furnish a due supply of nitrogenous aliment should be given with the 
farinaceous. Mothers pallid, and inclining to an anaemic condition, re- 
quire a larger proportion of animal diet than those in good general health. 
On the other hand, plethoric women, such as Routh describes, who with 
excellent appetite consume large quantities of food, and who become 
more and more full-blooded and corpulent while the milk diminishes, re- 
quire a more restricted animal diet, in connection with more exercise, 
especially in the open air. 



40 WEIGHT, GEO \V T H , LAC T ATIOX. 

There are certain kinds of food which do appear to have a galactogogue 
effect with most wet-nurses. Oatmeal gruel is one of these. Wet-nurses 
often remark, after taking a bowl of this, that they feel the flow of milk. 
Cow's milk with some has a similar effect, Porter or ale, taken once or 
twice a day, also promotes the secretion of milk, especially in those who 
ha\e poor appetite, and whose systems are somewhat reduced. 

A great variety of medicines have been used for their supposed galacto- 
gogue effect. Medicines which improve the general health are, no 
doubt, sometimes useful for this purpose, such as the vegetable and fer- 
ruginous tonics and, perhaps, cod-liver oil. But there are other medi- 
cines which it is claimed have a specific effect on the mammary gland, 
promoting its secretion. Lettuce, winter-green, fennel, the broom tops 
(scoparius), and marsh-mallow, have been used for this purpose. There 
can be no doubt that the aromatic stimulants, as fennel, anise, and cara- 
way seeds, given in soups, sometimes stimulate the lacteal secretion. 
Another medicine which of late has been recommended to the profession, 
as a galactogogue, is castor oil and the plant from which it is derived. 

The galactogogue effect of the leaves of the castor-oil plant has been 
long known to the Spaniards in South America. At least as long ago as 
the commencement of the last century, the ricinus communis was applied 
by them externally to the breast to promote the secretion of milk. It is 
now about twenty-five years since this use of the plant was brought promi- 
nently to the notice of the profession in this country and in Europe. In 
the London Journal of Medicine, 1857, Dr. Tyler Smith relates the results 
of his experiments with the castor-oil plant. He applied the bruised 
leaves over the breasts, and witnessed, as he thinks, an evident galacto- 
gogue effect. Dr. Routh has also made pretty extensive use of the plant, 
both externally and internally. He was led, he says, to employ it inter- 
nally, from noticing in suckling women an increase of milk after taking a 
dose of castor oil. He prescribed a decoction of the leaves and stalks, 
and says : " I have not been disappointed. The flow has been remark- 
ably increased. Four objections against its use, however, should be 
mentioned." These are, first a peculiar sensation in the eyes, with dim- 
ness of sight, an effect which he has observed only in weak women ; 
secondly, the necessity of increasing the dose as the patient becomes ac- 
customed to it ; thirdly, scarcity of the plant ; fourthly, an occasional 
diuretic, sometimes without galactogogue, effect, and sometimes with it. 
The cases in which diuresis occurred were in the practice of other physi- 
cians, and Dr. Routh conjectures that this effect was produced by not 
keeping the breast warm during the time that the decoction was being 
employed. The breasts should, at the time of its use, be covered with a 
fomentation of leaves, or an extract of the leaves should be rubbed over 
the breasts in the same way in which extract of belladonna is used, and 
over this a warm poultice applied of the ordinary material. Dr. Routh 



SCANTINESS OF MILK. 47 

remarks : ' ' When the castor-oil leaves are given as an infusion to women 
who are not suckling, I have observed two effects, both of which seem to 
denote its specific action. First, it produces internal pain in the breasts, 
which lasts for three or four days. Then, secondly, a copious leucorrhoeal 
discharge takes place, after which the effect on the breasts entirely disap- 
pears. " 

Dr. Gilfillan, of Brooklyn, has also employed the ricinus communis 
successfully as a galactogogue. He employed a poultice of the pulverized 
leaves, and gave internally the fluid extract of the leaves, a teaspoonful 
three times daily. The patient had been confined the year before with her 
first child, but had no milk for it, though her health was good, and meas- 
ures were employed, as friction and fomentations, to stimulate the secre- 
tion. The ricinus was prescribed the fourth day after her confinement 
with the second child, when there were no signs of secretion, and the 
breasts were small. " About two hours after the poultice was applied, 
and the first dose taken, she experienced a strange sensation in the 
breasts, and this increased after each dose of the medicine. The poultice 
was not renewed, but the extract was continued for three days, after which 
lactation was perfectly successful.'' So far, then, observations appear to 
show that ricinus is one of the most efficient galactogogues which we pos- 
sess among medicinal agents ; but all other modes of increasing the milk 
are probably less effectual than that which is natural, namely, suckling. 

In the treatment of galactorrhcea, the object to be attained should be 
kept in view. There are medicines which cure this affection by dimin- 
ishing the amount of milk. Belladonna, iodide of potassium, and eolchi- 
cum arc antigalactics. It is proper to use them in case of weaning or of 
death of the infant. They not only reduce the quantity of milk, but, 
continued, may prevent its secretion. They are employed not to benefit 
the infant, but the mother. 

On the other hand, if it be our purpose to prevent the oozing of milk in 
order to save it for the infant, or, if it be abundant and watery, to dimin- 
ish somewhat its quantity and improve its quality, the treatment should 
be different. Iron, in cases of galactorrhcea, in which the condition of 
the system appears to indicate the need of it, will diminish the quantity 
of milk and render it richer. It is by many regarded as an antigalactic, 
and, given long, it might reduce too much the amount of the secretion, 
and even necessitate weaning. Its use should be discontinued if no more 
than the normal amount of milk be secreted. 

In most cases of true galactorrhcea, the pathological state is that of 
weakness and relaxation of the tissues. The fault is not excessive secre- 
tion of milk so much as its non-retention, and the medicines which are 
he most useful to correct this state of the system and of the breasts are 
the vegetable tonics and astringents. If galactorrhcea occur in those who 



4S SELECTION OF A WET-NURSE. 

have an habitual discharge, and it appear to be due to the same cause 
which produces that discharge, and there be no evidences of weakness, 
laxative medicines and other derivatives may be employed. But such 
cases are not common. Nux vomica has been recommended in galactor- 
rhea, in the belief that it diminishes the relaxation of the orifices of the 
lactiferous tubes. 

Local treatment in this affection is important. A cloth wrung out of 
cold water should be occasionally applied around the nipple, and removed 
as it becomes warm. Solutions of tannin or alum are likewise useful. 
Collodion applied around the nipple, by the contraction which it pro- 
duces, diminishes the orifices of the ducts, and thus aids in the retention 
of the milk. 



CHAPTER V. 

SELECTION OF A WET-NURSE. 

In the cities, cases are frequent in which mothers, with all possible care 
or endeavor, find themselves unable to suckle their infants. Their health 
is too poor, or the milk possesses the properties of colostrum, or it is no 
longer secreted, on account of nervous excitement, or exhaustion, or in- 
flammation of the breasts. The number of such cases in the city would 
surprise physicians who are familiar only with the healthy and robust 
mothers of the country. The infant thus deprived of the mother's milk 
should, if practicable, be furnished with a wet-nurse. 

The selection of a wet-nurse often devolves upon the physician, and is 
a duty of great responsibility. It is better to select one between the ages 
of twenty and thirty years, and one who has suckled an infant previously. 
A wet-nurse between the ages of twenty and thirty is usually more active, 
cheerful, and conciliatory than one of a more advanced age, and her 
milk is more apt to be abundant and nutritious. Those who have previ- 
ously suckled and had charge of infants, are obviously more competent to 
serve as wet-nurse than are primiparse. The milk of a wet-nurse whose 
infant is under the age of six months, will ordinarily agree with a new- 
born infant. If above that age, it sometimes agrees, but often does not. 

The most difficult and responsible task imposed on the physician in the 
selection of a nurse, is to ascertain the exact condition of her health, and 
the quantity and quality of her milk. Constitutional syphilis is common 
in the class of women who present themselves for wet-nursing ; it is often 
latent, or its symptoms are easily concealed, and it is communicable by 
lactation. The virus may be received by the infant from fissures or ex- 
coriations of the nipple. The nursling tainted by syphilis may, on the 
other hand, communicate the disease to the nurse through the same 



EXAMINATION OF WET- NURSE. 49 

source. It is not fully ascertained whether the syphilitic virus may be 
conveyed to the infant by the milk. But the cases which have accumu- 
lated in the records of medicine are numerous, in which infants, born of 
healthy parents, have been fully syphilized by lactation from diseased 
nurses (see article Syphilis). These infants have sometimes led a short 
and miserable existence, and have occasionally increased the misery of the 
household by imparting the disease to others. The duty is, therefore, 
imperative on the part of the physician to examine carefullv the wet- 
nurse, in reference to any evidences of the syphilitic taint. Acquainted 
with the symptoms of syphilis, he may usually, by shrewd questioning 
and by careful examination of the present appearance and condition of 
the woman, ascertain with considerable certainty whether her system has 
ever been infected. References should also be obtained and consulted, 
and, if practicable, the physician who has attended her be communicated 
with. 

It is safer to employ a wet-nurse, two months after her confinement 
than previously, for if she have the syphilitic taint it will by this time 
show itself in the innutrition, coryza, and anal sores of her infant. 

There are, also, among the women who present themselves for wet- 
nursing in the cities, many of a scrofulous habit, and many who possess 
an hereditary tendency to tuberculosis, if indeed they do not already have 
the incipient disease. Such applicants should be rejected, on account of 
the poverty of their milk and the probability that they will not be able to 
endure the debilitating effect of lactation. 

The milk should be examined, in order to ascertain its richness and 
quantity, and whether it contain colostrum. If there be colostrum after 
the eighth day, it is probable that there is some fault in the health or 
digestion of the wet-nurse, and that her milk may disagree with the infant. 
It is not necessary that the breast should be large, in order to furnish a 
sufficient quantity of milk, since, as has been already stated, in some the 
secretory function is active during the time of each nursing, so that, 
although the breasts are of moderate size, a sufficient amount of milk is 
furnished. The nipples should be well formed and prominent, and prefer- 
ence is to be given to those wet-nurses in whom bloodvessels are seen 
ramifying over the breasts. 

By examination of the milk, its degree of richness can be readily ascer- 
tained. A quantity of it should be placed in a test-tube, and the cream 
which rises to the top indicates, approximately, the character of the 
milk. Good milk furnishes three per cent, of cream, and the casein and 
sugar usually correspond in quantity with the cream. An instrument has 
been invented, called the lactometer, by which the exact amount of the 
cream can be ascertained. It is simply a tube graded into 100 divisions. 
It is placed upright and filled with milk, and the number of divisions 
occupied by the cream indicates its proportion in 100 parts. The lacto- 



50 SELECTION OF A WET-NURSE. 

scope is another instrument employed for the purpose of ascertaining the 
richness of the milk. It consists of two concentric tubes, which move 
upon each other. Milk which we wish to examine is poured within the 
tubes sufficient to obscure a light viewed through it, three feet distant. 
The column of milk is then diminished, till the light begins to be visible. 
The size of the column indicates the degree of opacity and the richness. 
The lactoscope was invented by M. Donne, and is described by him. 

Dr. Minchin recommends a simple mode of determining the richness 
of cow's milk, and it would equally answer for the breast-milk. A vessel 
holding about one ounce, and containing a graduated enamel slab, pass- 
ing diagonally from above downward, is filled with milk. It is then 
covered with a glass slide carried over it in such a way as to exclude bub- 
bles. The number of degrees which can be read, indicates the character 
of the milk, as regards its richness. 

Examination of the milk with the microscope not only enables us to 
determine whether there are abnormal corpuscles or granular elements, 
but also its richness. It should be examined before the cream has sepa- 
rated. Oil-globules of small size, and few, indicate poverty of the milk ; 
very large oil-globules are said to indicate milk which is apt to be indi- 
gestible, especially in feeble infants. Such are the free globules of the 
colostrum. Numerous oil-globules of medium size indicate nutritious 
milk. Vogel, in ] 850, made the discovery of vibriones in human milk. 
The fact is established that these animalcules may be generated in the 
milk within the breast, though such cases are not frequent. Dr. Gibb 
describes a case which he met. (Banking's Abstract, vol. xxxiv.) An 
infant, seven weeks old, wet-nursed by its mother, who had the appear- 
ance of perfect health, was, nevertheless, ill-nourished and emaciated. It 
had no diarrhoea or other apparent disease, and the milk was therefore 
examined. Vibriones baculi were found in the milk immediately after it 
was obtained from the breast. The milk had the usual amount of cream, 
and seemed, to the naked eye, of good quality. According to Dr. Gibb, 
two genera of microscopic organisms occur in the milk, namely, vibriones 
and monads. It is believed that the monads occur in consequence of 
fermentation of the sugar and the production of lactic acid. Yogel also 
attributed the production of the vibriones to fermentation occurring in 
consequence of heat and congestion of the breast, connected with sexual 
excitement. This explanation is probably not correct, because vibriones 
sometimes occur when there is no unusual heat of breast, and no evidence 
of fermentation. The fact that such organisms may be found in milk 
which seems of good quality to the naked eye, affords additional proof 
of the usefulness of the microscope in the selection of a wet-nurse. 

Many wet-nurses have a return of the menses as early as the fourth or 
fifth month after delivery. The re-establishment of this function in some 
women impairs the quality of the milk, so as to render it less nutritious, 



EXAMINATION OF WET-NUKSE. 51 

and perhaps less digestible during the time of the catamenial flow, as we 
have stated in a preceding paragraph. In the selection of a wet-nurse, 
then, preference should be given to one who does not have the periodical 
sickness, but if she be already employed, and give satisfaction, the reap- 
pearance of the catamenia does not indicate the need of the change of 
nurse, unless the digestion of the infant be disordered, or its nutrition be 
impaired. 

In the selection of a wet-nurse, attention should also be given to her 
mental and moral traits. Cheerfulness, affection, veracity, and a proper 
appreciation of the responsibility of her situation, enhance greatly the 
value of a wet-nurse. Not less important are habits of temperance and 
cleanliness. I could cite cases of the most melancholy results from the 
absence of these traits. In one case, idiocy resulted from an infant falling 
upon the pavement from the arms of a reckless or intemperate wet- 
nurse. 

In most cases, the mode of examination indicated above suffices to show 
the character of a wet-nurse, so far as her health and milk arc concerned. 
It should be borne in mind, however, that the microscope does not always 
reveal deleterious properties in the milk. Elements which are in a state 
of solution, and are invisible, may occur in excess, so as to impair the 
quality of the milk and render it indigestible. The following case, in 
which the saline ingredients seem to have been in excess, is related by 
Dr. Hartmann (British and Foreign Medical Review, vol. xii.) : " An 
infant, whose mother was in good health and had borne several children, 
exhibited a healthy appearance for the first five weeks after birth. The 
alvine evacuations then became copious, fluid, and discolored, and the 
child lost flesh and strength. After the usual remedies had been vainly 
administered for a fortnight, the mother remarked that the child did not 
take the right breast willingly, and so much did the unwillingness increase, 
that at length the mere application of the nipple to the child's lips occa- 
sioned loud crying. On examination it was found that the milk of the right 
breast had a distinctly saline taste ; whereas the milk of the opposite 
breast was of the ordinary sweetness ; no difference of consistence or color 
was discoverable. From that time the child was only allowed to nurse 
the left breast, and in a few days nil diarrhoea and sickliness of appear- 
ance vanished." In this case there was no appreciable disease of the 
breast, although its secretion was perverted. The deleterious character 
of the milk was discovered, not by any change in its appearance, but by 
the taste. 

It is obviously very necessary, before recommending a wet-nurse, to 
ascertain whether she will probably furnish sufficient miljk ; for however 
excellent she may otherwise be, if she do not satisfy the wants of the 
infant she obviously should not be employed. The only certain way of 
ascertaining whether she have or have not sufficient milk is by weighing 



52 COURSE OF LACTATION — WEANING. 

the baby before and after the nursing;, and observing whether the differ- 
ence in the two weights corresponds with that given in the tables in Chap- 
ter VII. 



CHAPTEK VI. 

COURSE OF LACTATION— WEANING. 

After the birth of the infant, the mother needs rest a few hours — four 
or five, or a little longer in tedious and exhaustive cases — and then it 
should be applied to the breast. There is frequently a little milk at this 
time, and the act of nursing promotes the secretion, and increases the 
quantity. The full secretion is not, however, established before the third 
day, and though the infant be applied to the breast often, it obtains but 
little milk. Infants are so constituted that they require but little food 
until it is naturally provided for them, and the common practice of feed- 
ing them to repletion with various sweetened mixtures almost as soon as 
life begins, because they obtain little breast milk, is to be deprecated. 
Filling their stomachs in this way has a tendency to prevent their drawing 
upon the nipples with the avidity, which is required to stimulate a free 
flow of milk. Besides, as I have many times observed, indigestion, 
diarrhoea and sprue, are common results of this injudicious feeding. If, 
therefore, the infant be applied to the breast every second hour when the 
mother is awake till the third day, and be fed nothing besides, there need 
be no anxiety as regards its nutrition. If on the third day the breasts do 
not begin to fill, and the secretion be delayed, a little fresh cow's milk, 
diluted with double its quantity of warm water, and slightly sweetened, 
should be given every fourth hour, but should be withheld as soon as the 
flow of milk occurs. 

Infants under the age of one month should nurse about every hour and 
a half by day and at longer intervals by night, or about ten times in 
twenty-four hours, for the stomach of the new born holds but little, and 
therefore receives but little at each nursing, and its digestion is active. 
The interval should be longer at night than in the daytime, so as to 
allow the mother more sleep. In the second month the interval should 
be about two hours, and it should be gradually lengthened as the age in- 
creases, so that after the fourth month nursing should be about every third 
hour, and after the sixth month, when the use of some artificial food is 
proper, every fourth hour. 

The infant should be habituated to nursing at regular intervals, and 
when it is, it will ordinarily awaken at about the proper time. The prac- 
tice on the part of the mother of applying the babe to the breast whenever 
it frets, and as a means of quieting it, although it have but just nursed> 



AILMENTS OF NURSING INFANTS. 53 

is pernicious and should be forbidden. Giving the stomach no time to 
rest or filling it to repletion, tends to produce indigestion and diarrhoea, 
and to increase the fretfulness. The cause of the fretfulness should be 
sought for that the proper measures may be applied. In ignorance of 
the cause, it is better to quiet the restlessness by carrying the child, or 
even by rocking it, than to increase the task of the digestive function. 
Fretfulness of infants is often due to colic or griping in the bowels from 
gas or food that has not fully digested, and the addition of more food has 
a tendency to increase rather than to diminish it. 

While regularity in nursing is required, still, as M. Donne has said, 
mathematical exactness in this matter would be ridiculous. Quiet 
natural sleep of a well-nourished infant should not be interrupted, in order 
to give it the breast, unless the sleep be unusually protracted. It will 
usually awaken when the system requires more nutriment. Ill-nourished 
infants often sleep but little, making known their want by crying and 
fretfulness, until they become wasted and prostrated, when they are 
drowsy in consequence of passive congestion of the brain. This drowsi- 
ness is evidently a pathological symptom. It shows the need of increased 
nutrition. It is due to scantiness of milk or milk of poor quality, and the 
infant should be aroused frequently for the purpose of giving it nutriment 
or even stimulants. The breast milk is sufficient for its nutrition till the 
age of six or eight months, provided it is abundant and of good quality. 
Therefore, if the mother be strong, and experience no exhaustion from 
suckling, no other nutriment need be given till that age. 

Many mothers, however, by the third or fourth month of lactation, 
find that they have not sufficient milk to meet the wants of the infant. 
The constant drain upon their systems sensibly impairs their health. In 
such cases it is proper to commence with a little feeding from the spoon 
or bottle, and increase the quantity given as the infant grows older. 
Great care is, however, requisite in the preparation of food for so young 
an infant, whose digestive organs are still feeble and easily deranged. In 
the country, where diarrhceal affections and the so-called gastric derange- 
ments are not frequent, the danger from artificial feeding is less than in 
the city, and in the cool months in the city the danger is less than in the 
summer season. Infants of the city, between the months of May and 
October, have a strong predisposition to diarrhceal attacks, the result of 
anti-hygienic influences which surround them. Errors of diet in their 
case readily provoke disease or derangement of the digestive organs, often 
of a severe and dangerous form. Moreover, experience has shown that 
artificial feeding, during the period when nature designed that they 
should be nourished by lactation, verv commonly produces in the hot 
months more or less vomiting and diarrhoea, followed by emaciation and 
other evidences of mal-nutrition. Therefore an exception must be made, 
in case of the citv infant, as regards the commencement of artificial feed- 



54 COURSE OF LACTATION — WEANING. 

ing. If it be under the age of one year, it should be nourished exclu- 
sively, or almost exclusively, at the breast during the hot months, when 
practicable, even if the mother suffer somewhat in her health from the 
constant drain upon her system. It should, however, receive the 
amount of nutriment which it requires, and, if there be not sufficient 
breast-milk, it will be necessary to supply the deficiency by artificial feed- 
ing. The reader is referred to Chapter VIII., for facts relating to the 
subject of artificial feeding. 

No fixed rule can be stated in regard to the time when it is proper to 
allow artificial food in addition to the breast-milk. While robust mothers 
with abundant milk can satisfy their infants till the age of six or seven 
months, many begin to feel the drain upon their systems and have an 
insufficient supply by the third or fourth month, and it is necessary to 
supplement the nursing by the use of artificial food, a smaller or larger 
quantity, as the case may require. The deficiency may be supplied by 
the use of cow's milk, either employed alone or with barley or rice-flour, 
Liebig's or Ridge's food, or wheat flour prepared by long boiling, as 
recommended in Chapter VIII. At six months also, or even at four or 
five months, if the infant appear anaemic and ill-nourished, it may be 
allowed, occasionally, one or two teaspoonsful of beef-juice, expressed from 
slightly boiled beef, two or three times daily. At the age of eight months, 
semi-liquid food may be given. Pap, prepared with stale bread or a 
rolled soda-cracker, may also be given once or twice daily, between the 
times of nursing, and occasionally beef-tea or chicken-broth, thickened 
with cracker or bread, is taken with relish, and if well prepared and given 
no oftener than once or twice a day, it is commonly readily digested, while 
it is highly nutritious. If the quantity of breast-milk diminish, as it 
often does, toward the close of the first year, artificial food should be 
given oftener, so as to supply the deficiency. Solid food requires con- 
siderable development of the digestive organs for its ready assimilation. 
It should not, therefore, be given till the close, or near the close of the 
first year. 

Weaning ought to take place, as a rule, between the ages of ten and 
twelve months. It is well, if the mother's health be good and her milk 
sufficient, to defer weaning till the canine teeth appear. The infant then, 
possessing sixteen teeth, is able to masticate the softer kinds of solid 
food. Weaning should be gradual. Mothers often speak of weaning on 
a certain day. They have given but little artificial food, and have suckled 
at regular intervals, till at a fixed time they have denied the breast alto- 
gether. This abrupt change of diet should be discouraged. It should 
only be recommended under peculiar circumstances. It is apt to derange 
the digestive organs, and it causes fretfulness and sleeplessness on the part 
of the infant for a week or more. Weaning should commence by feed- 
ing with the spoon, a little oftener through the day, and nursing less, and 



QUANTITY OF FOOD REQUIRED. 55 

by discontinuing the practice of suckling at night. The infant tolerates 
this gradual change of diet, while it rebels against sudden weaning, and 
by its fretful ness increases greatly the care and trouble of the mother. 
Nurslings in the city should not be weaned in warm weather, nor within 
a month immediately preceding it. If the mother's health fail, or her 
milk become deficient in the summer months, so that she cannot continue 
suckling, the infant should be sent immediately to the country, or a wet- 
nurse be employed. Many lives are sacrificed in consequence of igno- 
rance of the danger of weaning under the circumstances mentioned. 
Severe diarrhoea, inflammatory or non-inflammatory, is apt to result. 
This subject will be considered elsewhere. 



CHAPTEE VII. 

QUANTITY OF FOOD REQUIRED IN INFANCY AND CHILDHOOD. 

There is no subject in the hygiene of infancy and childhood in regard 
to which so much ignorance prevails as the kind and quantity of food 
which is required at different ages. Physicians are frequently consulted 
in regard to the diet, and are expected to give full information in regard 
to the quantity as well as kind. As stated in a previous chapter, the only 
correct way of determining whether the mother or wet-nurse have suffi- 
cient breast-milk is by weighing the baby before and after the nursing, 
and comparing the difference with a correct standard. 

A striking example, showing the need of more accurate information in 
regard to the dietetic requirements of children, occurred, not long since, 
in one of the New York criminal courts. The superintendent of a chari- 
table institution was tried and sentenced to imprisonment for not furnish- 
ing proper and sufficient food to the children under his charge, and yet 
none of the summoned experts could state, except in a vague and general 
way, how much food a child of a given age needed. Impressed with the 
belief of the importance to the profession of more accurate information 
in regard to the quantity of food required by children to insure normal 
and healthy growth, I have prepared the following tables. 

The belief that children on account of being so much smaller, require 
much less nutriment than adults, leads many astray. The following sta- 
tistics, while showing how much food children need to do well and 
how much they receive in the large and well conducted institutions of 
New York city, will surprise such. The fact is, the digestion of children 
is more active than that of adults, and they suffer more from hunger if 
their meals be delayed beyond the usual time. Their tissues undergo 
more active molecular change than those of adults, so that they need more 



56 



QUANTITY OF FOOD REQUIRED 



nutriment for the waste, and they require additional nutriment for the 
purposes of growth. 

It will be seen from the statistics that new-born infants require less milk 
than those who are older, and that, after the first month, the amount re- 
quired is pretty uniform during the period of lactation. 

For the purpose of procuring accuracy in the observations, I obtained 
Fairbanks' scales, weighing to the half drachm. The infants were ac- 
curately weighed before and after each nursing, and the artificial food 
was weighed before and after each feeding. In this way the quantity 
taken at each meal was determined. The weights used were avoirdupois. 
The observations were made, at my request, by Dr. Kate Parker, resident 
physician of the New York Infant Asylum, and by Dr. Chadbourne, resi- 
dent physician of the New York Foundling Asylum, and I can vouch for 
their accuracy. The avoirdupois ounce contains 437.5 grains, and 
Dr. Chadbourne ascertained, by very careful weight and measurement, 
employing the metric system for its greater accuracy, that one fluid 
ounce of human milk, with a specific gravity of 1.031, weighed 451.9 
grains. With these data it was easy to determine the quantity in bulk of 
the milk from its weight. The observations in each case extended 
through twenty-four hours. 

TABLE I. — Age; under Five Weeks. 



No. 



1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 



Name. 



Josephine Foley. . . . 
Henry Cunningham. 

Henry Jackson 

Rake 

Henry Benton 

Win. 'Fletcher 

Nora Hastie 

Carl Flask 

Clarence Humphrey. 
Frederick Dili hie. . . 

Edward Stace 

Rosa Brown 



Age. 


No. of 

Nursings. 


17 d. 


11 


16 d. 


9 


19 d. 


9 


5d. 


12 


6d. 


12 


5d. 


12 


14 d. 


12 


5d. 


12 


m. 5 d. 


8 


7d. 


12 


6d. 


12 


3 w. 


12 



Milk Nursed in 24 Hours. 



Quantity in 
Fluid Ounces. 



Quantity in 


We 


lght. 


Oz. 


Dr. 


10 


* 


13 


5 


10 


3 


22 


7 


15 


5* 


10 


H 


17 


3 


5 


4 


11 


1* 


14 


4 


8 


1 


14 


1 



9.75 
13.24 
10.07 
22.22 
15.25 

9.88 
16.85 

5.37 
10.84 
14.08 

7.74 
13.68 



From these statistics it is seen that each of these infants, who were all 
under the age of five weeks, and all but two under that of twenty days, 
nursed in the average 12.41 fluid ounces of breast milk in twenty- four 
hours, and, as the average number of nursings for each during the day 
was 11.0, the quantity of milk received at each nursing averaged only a 



STATISTICS RELATING TO DIET 



57 



little more than one fluid ounce (1.12), or, to state the result of these 
observations in a different way, in 133 nursings of 12 infants in the twelve 
hours of day and twelve of night, the total quantity of milk received was 
148.97 fluid ounces with a daily average of 12.41 ounces for each infant, 
and 1.12 fluid ounce for each nursing. These infants were selected on 
account of their healthy condition, none of them showing symptoms of 
imperfect nutrition. They were selected as fair examples of healthy in- 
fants under the age of five weeks. The practical benefit from these 
observations is apparent. We can do no better than imitate what is 
natural in the feeding of infants, and if, for any cause, lactation of a new- 
born infant be prevented, it should not be fed more than one and one 
fourth ounces, each two and a half hours, of cow's milk, prepared as 
directed above, so as to resemble, as closely as possible, human milk. 
Newborn infants, deprived of the natural mode of feeding, are apt to 
be over-fed by anxious mothers, with the inevitable result of indigestion, 
diarrhoea, and unhealthy stools, colic and sprue. Statistics like the above 
may assist in correcting such error. 

The average quantity of milk which these infants, who were all well- 
nourished, received in the twenty-four hours, was 24.65 fluid ounces. 
The quantity received at each nursing was 2.73 fluid ounces in the aver- 
age. Comparing the statistics in the two tables, we find that infants in 
the first month require only half the nutriment which is needed in the 
subsequent months of the first year. In other words, the nursling, after 
the first three or four weeks, requires about one ounce of milk, for each 
hour between the nursings. If therefore it be bottle-fed, every third 
hour, with cow's milk, or other food, so prepared as to have about the 
same amount of nutriment as breast milk, three or three and a half ounces 
would be sufficient for each feeding. 

TABLE II.— Ages; from Five Weeks to Ten Months. 



No. 



Name. 



Age. 



A <mes Sunkle 16 m. 



Jessie Bradley. . . . 
Walter Gorman . . . 

Lottie Brooks 

Willie Leonard. . . 

jJohn Clay 

jAgnes West 

j Freddy Van Buren. 
lEddie Wilson 



4 m. 
3i m. 
7 ra. 
5i m. 

5 m. 
34- m. 
2 m. 

6 m. 



10 d. 



No. of 

Nursings. 



10 

11 

10 

8 

7 

10 



Milk Nursed in 24 Hours. 



Quantity 
Weight. 



Oz. 
26 
38 
24 
27 
28 
29 
19 
24 
12 



Dr. 

U 

i 
2 

3i 

7 
7 
2 
4 

4^ 



Quantity in 
Fluid Ounces. 



25.3 

36.8 
23.5 
26.6 
28.0 
29.0 
18.6 
23.7 
12.2 



58 



QUANTITY OF FOOD REQL'IKED. 



TABLE IL— Continued. 




Frank Smith. . . . 

11 Sarah White. . . . 

12 John Gafney. . . . 

13 IBernhard Joseph 

14 ;Thomas Cole 

15 lAstie Russell. . . . 



3im. 
4 rn. 
9 ra. 
7 m. 
6 m. 
6 rn. 



No. of 


Milk Nursed in 


24 Hours. 










Nursings. 


Quantity in 


Q 


lantity in 




Wi 


■ight. 


Fiu 


id Ouuces. 




Oz. 


Dr. 






8 


26 


7 




26.1 


8 


23 


5 




22.9 


8 


24 


1+ 




23.4 


8 


27 


4 




26.6 


10 


26 


6^ 




26.0 


10 


21 


6 




21.1 



The following observations, relating to the diet of children who have 
passed beyond the age of lactation, were made in the Xew York Found- 
ling Asylum, with all possible care in order to avoid errors. In this in- 
stitution children are not stinted in their eating, but those who eat little 
are reminded of their remissness, and are urged to eat more, so that no 
one leaves the table hungry. On the day in which Dr. Chadbourne 
made the observations, vegetables, except potatoes, were withheld, so that 
computation of the quantity of food consumed would be more accurate. 

TABLE III. — Observations Relating to the Diet during Twenty-four 
Hours, of Twenty -eight Healthy Children, between the ages of Two 
and Three Years, with an Average Age of Two Years Eight Months. 





Total Amount. 


Average for each. 


Breakfast. 
Bread 


6 lbs. 
22 lbs. 

8 lbs. 
6 lbs. 

i; lbs. 

19 lbs. 

: lbs. 


4 oz. 

13 oz. 

14 oz. 

oz. 

13 oz. 
9 oz. 

12 oz. 

1 oz. 

14 oz. 


1 dr. 
5 dr. 

2 dr.* 

5 dr. 
7 dr. 
7 dr. 

1 dr. 

2 dr. 
7 dr. 


3.5 oz. 


Butter - 


.45 oz. 


Milk 

Meat ... 
Potatoes 


DlXXER. 


12.7 fl. oz. 

4.6 oz. 
3.9 oz. 


Milk .... 
Milk 


Supper. 


9.4 fl. oz. 
10.5 fl. oz. 


Bread 

Butter 


4.0 oz. 
.53 oz. 



354.6 riuid ounc< 



STATISTICS RELATING TO DIET. 



59 



AVERAGE FOR EACH CHILD PER DAY. 



Bread, 
Butter, 
Meat (beef), 
Potatoes, 
Milk. 



7.5 oz. avoir. 

.98 oz. " 

4.6 oz. " 
3.9 oz. " 

32.6 fl. oz. 



TABLE IV. — Observations upon Twelve Children between the Ages of 
Three and Six Years : Average Age, Four Years Ten Months. 





Total Amount. 


Average for each. 




Breakfast. 






Bread . . 

Butter. . 
Milk 




4 lbs. 6 oz. 3^ dr. 

5 oz. 2 dr. 
280 fl. oz. 


5.86 oz. 
.427 oz. 
23.3 fl. oz. 




Dinner. 




Beef. . . . 
Bread. . . 
Rice. . . . 




9 lbs. 1 oz. 3 dr. 
1 lb. oz. 1 dr. 
9 lbs. 12 oz. 7 dr. 
112 fl. oz. 

2 oz. 2£ dr. 


12.1 oz. 

1.6 oz. 

13.0 oz. 


Milk 


9.3 fl. oz 


Butter. . 








Supper. 






Bread . . 
Butter . 





2 lbs. 4 oz. H dr. 
5 oz. 5^ dr. 
192 fl. oz. 


3.0 oz. 


Milk 


16.0 fl. oz. 



average per day for each child. 



Milk, 
Beef, 
Rice, 

Bread, 
Butter, 



48.6 fl. oz. 
12.1 oz. avoir. 
13.0 oz. " 
10.3 oz. " 
1.08 oz. " 



TABLE A". — Observations relating to the Diet of Twenty-four Children, 
Twelve Bogs, Twelve Girls, between the Ages of Four Years and 
Ten Years : Average, Six Years Ten Months. 





Total Amount. 


A\ 


erage for each. 


Bread. . . 


Breakfast . 


7 lbs. 13 oz. 3 dr. 
12 oz. 3^ dr. 
348 fl. oz. 




5.21 oz 


Butter 


.51 oz. 


Milk 


14.5 fl. oz. 



60 



QUANTITY OF FOOD REQUIRED. 



TABLE V .—Continued. 





Total Amount. 


Average for each. 


Roast Beef. 


Dinner. 


18 lbs. 11 oz. dr. 
15 lbs. 8 oz. 3 dr. 

lib. Goz. idr. 

192 fl. oz. 

4^dr. 

6 lbs. 2 oz. 3^ dr. 
384 fl. oz. 

11 oz. 5i dr. 


12 46 oz. 


Potatoes . . . 

Bread 

Milk 

Butter 

Bread 


Supper. 


10.30 oz. 
.92 oz. 

8.0 fl. oz. 
.012 oz. 

4.1 oz. 


Milk 

Butter. . . 


16.0 fl. oz. 
.16 oz. 









AVERAGE PER DAY FOR EACH CHILD. 



Roast beef, 
Bread, . 
Potatoes, . 
Butter, . 
Milk. 



12.46 oz. 
10.23 oz. 
10.3 oz. 
.99 oz. 
38.5 fl. oz. 



Compare the above observations with those of Professor Dalton, who 
estimates that a healthy adult taking active exercise requires each day — 

Meat, 16 oz. 

Bread, e 19 oz. 

Butter, 3^oz„ 

Water, 52 oz. 

while one leading a sedentary life needs considerably less. 

It will be seen by the above tables, that even more food appears to be 
needed during the period of childhood than in adult life. We would 
suppose this to be so without statistical evidence, for the active exercise, 
and rapid and progressive growth of this period would necessarily require 
a large amount of nutriment. Moreover while adults do well with solid 
food and water, statistics show that the best diet for children who have 
passed beyond infancy, is one of milk with solid food, for at least break- 
fast and supper. 

Although we are able, by observations, to determine the average 
amount of food required in twenty-four hours, by children of various 
ages, it would be wrong to limit the diet to a fixed quantity, for some 
need more than others. A child should never go hungry after a meal. 
In some of the best conducted institutions of New York, the children 
eat of plain food all that they desire at each meal, while in other institu- 



ARTIFICIAL FEEDING. 



61 



tions the food at supper is limited, but is abundant at the other meals. 
As children go to bed so soon after supper, it is proper to have this meal 
light, and of such food as is easily digested. 



CHAPTER VIII. 



ARTIFICIAL FEEDING. 

Occasionally the mother is unable to suckle her infant, and a hired 
wet-nurse cannot be or is not obtained. Artificial feeding is then neces- 
sary. In the large cities, if I may judge from our New York experience, 
this mode of alimentation for young infants should always be discour- 
aged. It generally ends in death, preceded by evidences of faulty nutri- 
tion. A considerable proportion of those nourished in this manner thrive 
during the cool months, but on the approach of the warm season they are 
the first to be affected with diarrhoea and other symptoms indicating 
derangement of the digestive function. In my opinion, based on a 
pretty extended observation, in New York city more than half of the 
artificially fed infants, who enter the summer months, die before the 
return of cool weather, unless saved by removal to the country. In the 
country, and in the small inland cities, the results of artificial feeding are 
much more favorable. The majority live, and in elevated farming sec- 
tions, on account of the salubrity of the air, and the facility with which 
milk, fresh and of the best quality, is obtained, artificial feeding is at- 
tended by little risk. 

Young infants, fed by the hand, obviously require food prepared so as 
to resemble as closely as possible the human milk. The basis of such 
food must, therefore, be the milk of some animal. The following table, 
prepared by MM. Yernois and Becquerel, gives the proportion of the in- 
gredients of human milk, and the milk of the four domestic animals 
which is most easily obtained, and most frequently employed as food : 

Composition of Milk. 





Specific 
Gravity. 


100 parts contain 


The solid components consist of 




Fluids. 


i 1 

Solids. Sugar. I Butter. 


Casein 
and ex- 
tractive 
matters. 


Salts. 


Human 

Cow 


1032.67 
1033.38 
1034.57 
1033.53 
1040.98 


889.08 
864.06 
890.12 
844.90 
832.32 


! 

110.92 1 43.64 26.66 
135.94 38.03 36.12 
109.88 i 50.46 j 18.53 
155.10 36.91 ! 56.87 
167.68 ! 39 .43 ; 54 21 


39.24 
55.15 
35.65 
55.14 

69.78 


1.38 
6.64 


Ass 


5.24 


Goat 

Ewe 


6.18 
7.16 






~ 





62 ARTIFICIAL FEEDING. 

Cow's milk is most readily obtained, and is commonly used as a sub- 
stitute for human milk, compared with which it contains less water and 
sugar, but more butter, casein, and salts. Its composition, however, 
varies considerably, according to the food of the cow and other circum- 
stances. The variations in the milk of the cow, according to the nature 
of its food, have been considered in a preceding chapter. It has been 
stated, also, that the milk first obtained in milking is most watery, since 
it is longer secreted than the last milk, or the " stripping." The stall- 
fed cow gives acid milk, while the cow grazing in a pasture gives milk 
that is alkaline. Again, the milk in the first months after calving is 
richer than after the lapse of several months. 

It is obvious from the above facts, that the analyses of different specimens 
of cow's milk must differ greatly, and the same is true of the milk of the 
goat and ass, and probably of the ewe. In fact, different samples of the 
milk of the same animal may differ more from each other, in their chemical 
character, than the average milk of one animal from that of another. 

The milk of the goat and that of the ass have been recommended as 
food for infants in preference to cow's milk, on the ground, as is alleged, 
that they more nearly resemble human milk. But by reference to the 
foregoing table, it will be seen that more importance has been attached to 
this supposed resemblance than the facts justified. Neither the milk of 
the ass nor goat, so far as its chemical character is concerned, would seem 
to possess any advantages over cow's milk. The ass's milk is procured 
with difficulty, and is seldom used. An objection to goat's milk is the 
unpleasant odor which it often possesses, due to the presence of hircic 
acid. It is stated, however, by Parmentier, that this odor is only 
noticed in the milk of goats that have horns. An important advantage, in 
the city, in the use of goat's milk, is that the animal can be kept at little 
expense, so that even poor families who are not able to purchase and feed 
a cow, can generally possess a goat from which fresh milk can be obtained 
at any time. Preference is to be given to goat's milk, when fresh, over 
cow's milk brought from the country, perhaps watered on the way, and 
several hours old when received. If, however, as both chemical analysis 
and experience show, goat's milk is no better as food for infants than 
cow's milk when fresh and from healthy cows, the latter must continue 
in common use for this purpose. 

Milk used for infants should be alkaline or neutral. If it be decidedly 
acid, as shown by the proper test, it should be rejected ; or, if there be 
none better, should be rendered alkaline by the addition of lime-water or 
carbonate of sodium. The nurse should test the milk at different periods 
through the day, and be taught to make the necessary addition. We 
often hear parents say with satisfaction that they obtain one cow's milk, 
"but milk from several cows is, in my opinion, preferable, as a rule, as it 
is apt to give a better and more uniform average in its ingredients. 



RULES FOR ARTIFICIAL FEEDING. 63 

Milk should always be given at a uniform temperature, namely a little 
warmer than the body. Employed habitually too hot or too cold, it is 
apt to cause stomatitis, if not a more serious disease of the digestive 
organs. Infants sometimes take the milk more readily if a little sugar be 
added. Pulverized sugar of milk, kept in the shops, may be added, one 
teaspoonful to five or six ounces of milk, or cane sugar may be employed. 
In case of constipation cane sugar is preferable, as it is more laxative. If 
the milk produce symptoms of indigestion, the addition of a little salt is 
sometimes useful. 

Infants under the age of six months should take food through the nursing- 
bottle at the temperature of about 984°, and the bottle as soon as used 
should, with the India rubber tip and attachment, be put in a quart or 
two-quart bowl of cold water, to which a teaspoonful of bicarbonate of 
sodium has been added ; and this water should be drawn through the tube 
and nipple by suction with the mouth. As the infant under the age of 
one month, when in the normal state, nurses the breast about ten times in 
twenty-four hours, it should have the bottle about every two and a half 
hours. The stomach during the first six weeks of life is very small, re- 
sembling more a dilatation of the intestines than a separate organ, not re- 
ceiving more than one or two ounces of liquid without distension. 
Therefore, while it is fed so often, it is evident that the quantity given 
each time should be small, and such as will be quickly digested and 
absorbed. In the first month after birth the cow's milk should be diluted 
with half its quantity or sometimes an equal quantity of water ; from the 
second to the fifth month, with one-third to one-fourth its quantity ; and 
after the sixth month it should be employed without dilution. 

The shops contain many substitutes for human milk, but cow's milk, 
if it can be obtained fresh from healthy grass-fed or hay-fed cows, is to 
be preferred to any of them for ordinary feeding. Condensed milk pos- 
sesses no advantages which render it superior to ordinary milk, if the latter 
can be obtained directly from the animal and sufficiently often. 

When shall other food be allowed in addition to cow's milk, and what 
kind of food ? Cow's milk given unmixed with other kind of food, does 
not always agree with the infant. Possessing nearly the same chemical 
constitution as human milk, it nevertheless behaves differently, in some 
respects, in its digestion. The casein of human milk coagulates in light 
flocculi in the stomach of the infant, so as to be readily acted on by the 
digestive fluids, while that in cow's milk is apt to form large and firm 
coagula, which are with difficulty digested, and which, therefore, may 
cause colic and fever and make the infant restless, or cause vomiting, by 
which the mass is expelled ; or it may pass the bowels only partially 
digested, and appear in the stools as whitish masses. 

An alkali taken with the cow's milk retards the coagulation of 
casein, and tends to prevent the formation of large and thick curds. 



64: ARTIFICIAL FEEDING. 

If therefore the child vomits curds, or passes fragments of them in 
the stools, or if the stools be acid, lime water may he added, or 
the carbonate of sodium as recommended by VogeJ, who dissolves one 
drachm of the carbonate in six ounces of water, and adds a teaspoonful 
to the milk at each meal. A more effectual way to prevent the formation 
of large and firm caseous coagula, is to mix with the milk some bland and 
easily digested farinaceous food which, by mechanically separating the 
caseous particles, prevents the formation of large masses ; and which, 
while it has nutritive properties, dilutes the milk and enables the digestive 
fluids to act more readily upon it, the desired effect is attained of facili- 
tating digestion without impairing the nutritive properties of the milk. 

The belief has prevailed in the profession, that infants prior to the third 
or fourth month can digest only a very small amount of starch, since the 
salivary and pancreatic glands, whose secretions convert starch into 
glucose, a necessary change in digestion, are almost rudimentary in the 
first months of infancy. In a monograph relating to Infant Diet written 
by Professor A. Jacobi, and revised, enlarged, and adapted to popular 
reading by Dr. Mary Putnam Jacobi, it is stated that the parotid glands 
which, together, weigh 80 grains at fifteen months, and 120 grains at two 
years, weigh but 34 grains at the age of one month. In several instances 
we weighed the pancreas taken from the bodies of infants who had died 
under the ao-e of six months in the New York Infant Asylum. Its weight 
was very different in those whose ages were about the same ; in several 
under the age of four months it was less than one drachm and in some 
more than one drachm ; but in no instance did it reach two drachms. 
The submaxillary and sublingual glands, which also secrete a liquid that 
is designed to convert starch into glucose, are comparatively insignificant 
in young infants, so that the combined action of the parotid, submaxillary, 
sublingual and pancreatic secretions, must be inadequate for the sacchari- 
fication of the starch which ordinary farinaceous food contains, during 
the first three or four months of infancy. 

But it is now ascertained that the salivary and pancreatic secretions are 
not the only agents by which starch is digested. The mucous surface 
furnishes an " epithelial ferment, which assists in the change, so that 
the secretions from the buccal and intestinal surfaces materially aid in the 
digestion.' 1 {Revue des Sciences Med., 1879, by Charles Richert) ; also 
remarks by Professor Flint Jr. , in Physiol, of Man. 

It appears, therefore, that young infants are able to digest a certain 
amount of starch, but a much smaller proportion thau those who are 
older ; and the preparation of a farinaceous food in which saccharification 
of the starch is effected by a chemical process, and the delicate and easily 
deranged digestive organs of the infant relieved of the task, has long been 
a desideratum. 

The late Baron Liebig, who devoted considerable time in the last years 



L I E B I G-' S FOOD FOR INFANTS. 65 

of his life to the study of the food of infants, prepared such an article, 
widely and favorably known on both continents as Liebig's food. Havv- 
ley's Liebig's food, made by Dr. Hawley, of Brooklyn, has been in the 
shops for some years. More recently, Liebig's food made by Mr. Hor- 
lick, of Chicago, and that by Mr. Mellin, of London, which are nearly 
identical, have come into use. Being carefully prepared according to 
Liebig's formula, by chemists fully competent, they possess certain ad- 
vantages, such as quick and easy preparation and a pleasant flavor, and 
are, therefore, highly esteemed by those who have employed them. 

The accompanying statements show us the nature of Liebig's food, and 
the way in which it is prepared. Starch is transformed into sugar and 
dextrin, a change which, when farinaceous substances are used in the usual 
way, is effected in the system, and thus the digestive organs are relieved 
from a part of the burden of digestion. 

" The following is the best way of preparing this food : Half an 
ounce of wheaten flour, and an equal quantity of malt flour, seven grains 
and a quarter of bicarbonate of potassium, and one ounce of water are to be 
well mixed ; live ounces of cow's milk arc then to be added, and the 
whole put on a gentle fire. "When the mixture begins to thicken, it is 
removed from the fire, stirred during five minutes, heated and stirred 
again, till it becomes quite fluid, and finally made to boil. After the 
separation of the bran by a sieve, it is ready for use. By boiling it for a 
few minutes, it loses all taste of the flour." (London Lancet, January 
7th, 1865 ; Braithwaite^ s Retrospect, July, 1805.) 

This food, according to Liebig, furnishes double the amount of nutri- 
ment contained in milk ; or, as he expresses it, is a " double concentra- 
tion" of that secretion. 

Dr. Hasscll, in a communication in reference to this food to the Lon- 
don Lancet for July 29th, 1865, says : 4 ' It appears to me that the great 
merit of Liebig's preparation consists in the use of malt flour as a consti- 
tuent of the food ; this, from the diastase contained in it, exercises, when 
the fluid food or soup is properly prepared, a most remarkable influence 
upon the starch, quickly transforming it into dextrin and sugar, so that 
in the course of a few minutes, the food, from being thick and sugarless, 
becomes comparatively thin and sweet.'' 

..." Correct and ingenious as are the principles upon which this 
food has been designed, yet the directions given for its preparation are 
certainly open to considerable improvement. Thus, Liebig directs that 
the malt should be ground in a common coffee-mill, and the coarse 
powder passed through a sieve. This necessitates the subsequent strain- 
ing of the food, a tedious operation, in order to remove the bran and re- 
maining particles of husk. And further, that the food should be put 
upon a gentle fire previous to its being finally boiled. Now, a gentle 
heat may mean almost any temperature nearly up to the boiling-point ; 



6G ARTIFICIAL FEEDING. 

and since the action of the diastase is destroyed at about 150° F., the 
temperature should never be allowed to exceed that degree. 

" I recommend, therefore, that the malt should be well freed from 
husk, and finely ground ; that the wheat flour should be lightly baked ; 
and finally, that a thermometer should be employed in the preparation of 
the food. Indeed, in some samples recently submitted to me by Messrs. 
Savory <fc Moore, I find that the first two points have been attended to, and 
that they use malt freed from husk and finely ground, and the wheat flour 
baked. 

" The effect of baking the wheat flour is to partially cook the starch 
entering into its composition, so that less heat is required in the prepara- 
tion of the liquid food. I find that a temperature ranging between 140° 
and 148° is amply sufficient to effect the complete transformation and 
solution of the starch-corpuscles, and, indeed, to cook the food suffi- 
ciently." 

Dr. James S. Hawley, who has given much attention to the prepara- 
tion of Liebig's food, and who now furnishes the market with it, says : 
" The principal objection which has been urged against Liebig's food is 
the difficulty of its preparation. This objection certainly did lie against 
the process recommended by its author, and against many of the direc- 
tions since proposed. But . . . the simplest form of cooking is all that 
is requisite. This consists in mixing the dry food, properly compound- 
ed, with milk or water (better milk), and slowly bringing it to a boil with 
frequent stirring ; or heating it until it begins to thicken, then remove it 
from the fire and stir until it grows thin, and repeat this process two or 
three times. At the close of the process it will be quite thin and sweet. 
No food can be cooked in a simpler manner than this. This dissolving 
of the thick, hydrated starch is itself the evidence of the transformation 
of amylum into glucose. It is not claimed, that by this simple method, 
all the starch is converted, but that its percentage is very greatly dimin- 
ished, sufficiently so to afford abundant assimilable nutriment to the in- 
fant, and also to avoid the dangers and inconveniences arising from the 
presence of indigestible matter in the intestines." 

Liebig's food if given in considerable quantity, is laxative, from the 
large amount of grape sugar which it contains, and therefore, while useful 
in a constipated habit, it cannot be recommended, unless in small quantity, 
for infants who have a tendency to diarrhoea. 

Milk should, however, be the chief article of food during the first year, 
and one of the chief during the whole period of infancy, but after the 
age of six months, it is proper to allow some solid food. The quantity of 
solid food should be increased and that of milk diminished as the infant 
grows older, but during the second and third years as well as during the 
first, milk should be allowed each day at, at least, certain of the meals. 
At the age of twelve months the artificial food already mentioned may 



RULES FOR ARTIFICIAL FEEDING. G7 

be made of greater consistence, so as to be given with the spoon. 
Crumbs of stale bread broken up should be boiled in water sufficient to 
cover them, for one or two hours, then removed, and to the pulp fresh 
milk be added. This may be given one or more times daily in addition 
to the nursing, care being taken that all lumps be reduced to a pulp. 
Beef tea is laxative, on account of the salts which it contains, as is also 
chicken tea ; but a small, or moderate amount of it may be given once a 
day. Stale wheat bread or soda cracker should be crumbled in it and 
soaked, so as to be soft. If there be diarrhoea, the ordinary beef tea 
should not be allowed to young infants, on account of its laxative effect, 
but the expressed juice may be given instead. Few vegetables are proper 
for infants under the age of one year, but the potato, baked and mashed 
so as to be like flour, may be given at the tenth or twelfth month. It 
contains a large amount of starch, but appears to be readily digested by 
infants of the age mentioned, if given once a day in moderate quantity, 
with a little butter and salt added. In the second year a greater variety 
of food may be allowed, but the full diet of the table must not be given 
till after infancy, or the age of three years. In the beginning of the 
second year the infant is weaned. He has twelve teeth, eight in- 
cisors, and four molars, which, with their broad surfaces, are designed 
for chewing. Let him have now, each day or second day, in addition to 
the food which has previously been employed, a small piece of roast beef, 
rare done and cut very line. Other meat, as mutton, may sometimes be 
given instead. After the age of eighteen months, light puddings of 
farinaceous substances, properly prepared, as of rice and corn meal, are 
proper additions to the dietary. 

All tne teeth of the first set have appeared at the age of two years and 
five months, and the time has now arrived when a more marked transition 
may be made from liquid to solid food. Certain fruits may be allowed, 
even before this period ; as also the jellies of most berries, and of fruits, 
which being deprived of seeds and parenchyma arc for the most part 
readily digested, while they give a relish to the farinaceous food with 
which they are eaten. Pastries as ordinarily made, whatever fruits thev 
may contain, are too rich and indigestible for young children. The fol- 
lowing judicious rule for the preparation of fruits for children, copied in 
popular treatises on hygiene of infancy and childhood, is from " Murray's 
Modern Cookery Book." ..." Put apples sliced, or plums, currants, 
gooseberries, etc., into a stone jar, and sprinkle among them as much Lis- 
bon sugar as necessary ; set the jar in an oven or on a hearth, with a tea- 
cupful of water to prevent the fruit from burning ; or put the jar into a 
saucepan of water, till its contents be perfectly done. Berries and fruits 
thus prepared, and the fruit jellies, are best eaten spread on bread and 
butter, or on soda crackers. " 

The shops contain various dietetic preparations which under certain c'r_ 



68 BATHING, CLOTH TNG, SLEEP, EXERCISE. 

cumstances may be employed in place of fresh milk. Among the best of 
these are the condensed milk, both the American and Swiss. Next is lac- 
teous farina, Ridge's food and imperial granum. 



CHAPTER IX. 

BATHING, CLOTHING, SLEEP, EXERCISE. 

Bathing is now recognized in all civilized countries as one of the chief 
promoters of bodily comfort and health. The first bathing of the infant, 
which is immediately after birth, should be in water at a temperature a 
little below that of the blood, namely, at about 96°, after which the 
general bath is inadmissible until the navel string is detached. In the in- 
fant, reaction of the surface when chilled is tardy and uncertain, and there- 
fore there is great danger of catching cold when the surface is cooled by 
water, and does not quickly react. It is a matter of daily observation 
that infants become chilly and their extremities remain cool in a medium, 
whether air or water, in which older children and adults would have com- 
fortable warmth. Therefore they are liable to contract bronchitis, sore 
throat, intestinal catarrh, or other inflammation, from very slight expos- 
ures. This fact must be borne in mind in considering the subject of 
bathing. 

During the first year after the detachment of the navel string, the bath 
should be employed daily, but not longer than three minutes ; during 
which time thorough ablution can be performed. Different authorities 
disagree in regard to the proper temperature of the bath during the first 
months of infancy. Steiner of Prague, a high authority in children's 
diseases, says, " During the first nine months the infant should have a 
daily bath a little above blood heat," . . . but most state a temperature 
a little below blood heat. In my opinion it should be 92°, which is con- 
siderably below blood heat, but which communicates a moderately warm 
sensation to the hand. After the a^e of ten months, or even of eio;ht 
months for vigorous children, the temperature of the bath may be reduced 
to 90°, and it should not be lower than this during the remainder of in- 
fancy, or if it be used a little lower, care should be taken to produce re- 
action by brisk rubbing and exercise, after a short bath. At the close of 
infancy, namely at two and a half years, the temperature may be still 
farther reduced, but it should not, even for the most robust children of 
eight or ten years, be below 78°, which is recorded on our thermometers 
as the temperature of summer heat, and is about that of our northern 
lakes daring midsummer. 

The rules given in the books ; not to bathe or direct a child to be bathed 



CLOTHING. 69 

immediately after eating, or after much exercise, when the pores of the 
skin are perspiring, should be heeded. The head should first be wet with 
the water, and Castile soap should be applied over the surface to insure 
cleanliness. The strongly scented toilet soaps sometimes contain rancid 
fats, or other deleterious substances, and should be regarded with suspi- 
cion. In hot weather a daily bath is advisable, but in the cooler months 
it is sufficient if the child bathe twice or three times in the week. If 
from lack of conveniences, or for other reasons, general bathing be dis- 
pensed with and the surface be washed from a basin or bowl, cooler water 
may be used than would be proper for the general bath, and a longer time 
to complete bathing would evidently be required. The bath-room should 
be comfortably warm, and after the bath, the surface should be briskly 
rubbed with flannel, or in case of the older children, with a suitable coarse 
towel, and exercise afterward encouraged to insure full reaction. In New 
York, in one of the largest and best managed asylums, both boys and 
girls are allowed to bathe, in bath houses, in the Hudson when the water 
and weather are not too cool. 

It may be well to add to these general remarks on bathing the recent 
remarkable statement of a high authority on thermometric observations and 
temperature, that, during hot days, a bath in hot water, employed in the 
hours of greatest atmospheric heat, tends to reduce the heat of body and 
to preserve its normal temperature during the remainder of the day. 
Wunderlich, says " in tropical countries and in very hot seasons, no 
means of cooling is so lasting as a bath or douche of very warm water." 

Clothing. 

One of the most important duties of the mother or nurse is the selection 
of clothing for children which will be suitable for their age and the season. 
In the matter of dress, as in that of diet, many errors are unconsciously 
committed. In a room of proper temperature, which during the cool 
months should be 70° for infants and G8° for children old enough to run 
about, the head should never be covered unless in case of young infants, 
but the sides of the head as well as the neck and shoulders may be lightly 
covered in sleep. It is the common practice to leave off the " belly- 
band" which is applied after birth, when the infant has reached the age 
of three or four months, but from the fact that infants so often take cold, 
especially at night by throwing off bed clothes, both in cool weather, 
when the temperature of the apartment may fall below 70°, and in sum- 
mer when there are currents of air through open windows, I advise the 
continuance of the band during the first year or eighteen months. In the 
summer it should be made of light merino, and in the winter, of flannel. 
It should never be so thick and heavy as to be uncomfortable, or so snug 
as to interfere in the least with the free movements of the chest and abdo- 
men in respiration. It should extend to and not over the ribs, and 



70 BATHING, CLOTHING, SLEEP, EXERCISE. 

should be secured either with safety pins or a few stitches. If excoria- 
tions or prickly heat appear on the skin under the band in hot weather, 
a very common eruption in infancy, the surface should be dusted with 
subnitrate of bismuth, or a mixture in equal parts of lycopodium and oxide 
of zinc, and a single layer of linen should be applied over it and under 
the band. If the eruption be severe, it might be best to substitute a 
linen or soft muslin band for a time in place of the merino. 

A cardinal principle in the clothing of children is that the garments 
should always be so loose as not to interfere in the least with the functional 
activity of organs. The fitting and putting on of the dress is left too 
much to the discretion of the nurse, who is usually ignorant of the im- 
portant facts in physiology, and unwittingly and with the best intentions, 
injures her charge. I have often interposed to loosen the dress of young 
infants, which was so tight as to sensibly embarrass respiration, and the 
case of a new-born infant has been reported to me in which it seemed 
probable that death resulted from this cause. Infants especially, who are 
so liable to pulmonary collapse and intestinal hernia, should have loose 
covering of both chest and abdomen. Pressure over the stomach always 
feels uncomfortable, and this organ, almost as much as the lungs, needs 
full expansion and free movement, in order to perform its function of 
digestion properly. The same is true also of the intestines, but they 
tolerate compression better, and their movements are less impeded than 
those of the stomach by too tight dressing. Another part, where too 
snug an application of the dress docs very great harm, is the neck, since 
moderate pressure in this region may retard the circulation of blood 
through very important vessels, namely, those which supply the brain, or 
return blood from this organ. The dress about the neck should always 
be so loose that the four fingers of the nurse can be readily introduced 
underneath it. Skirts upon girls are sometimes supported by being tied 
tiffhtlv around the waist and over the stomach. This should never be 
allowed, but they should always be supported by shoulder straps, and be 
loose around the waist. 

Clothing protects the body according to its thickness and the feeble- 
ness of its conducting power of heat. Woollen, fur, and feather gar- 
ments have very low conducting power, and wool, from its plentiful sup- 
ply and cheapness, must always be the material which is chiefly Avorn in 
the winter season, while cotton, and in still greater degree, linen, are 
active conductors of heat, allowing its quick escape from any part of the 
body which it covers, and they are therefore the proper material for sum- 
mer clothing. 

The color of a garment matters little as regards the escape of heat from 
the body, for whatever its color its surface next the body is necessarily 
dark from the exclusion of light ; but the color is important as regards 
the absorption of heat from the atmosphere and the solar rays. Black 



SLEEP. 71 

has the highest absorptive power, while white has the least, and the 
mixed colors have absorptive powers which arc intermediate. In experi- 
ments made of shirtings of different colors, while white received 100° F. 
black received 208° F. A light color is therefore the best to dress chil- 
dren in during the hottest weather. 

The covering which is proper for the head of a child when outdoors, 
must evidently vary considerably in different seasons, and in different 
states of weather. Many a young child, with scanty growth of hair, has 
contracted that painful disease, inflammation of the ear, followed perhaps 
by a protracted discharge, and more or less impairment of hearing, in 
consequence of taking cold from insufficient covering of head and ears in 
inclement and changeable weather ; even leaving off accidentally a band 
or tie to which a child is accustomed will sometimes give it a cold. 

In this connection, I wish to call attention to the common and danger- 
ous practice among the poor of allowing children to go bareheaded in the 
sun during the season when the atmospheric heat is highest. Not a sum- 
mer passes in which I do not meet cases of inflammation of the brain, 
which I believe to be largely due to exposure to the sun's rays. There 
is no better and safer covering of the head of a child, who is allowed to 
go in the open air during the hot weather, than the light, cool, and inex- 
pensive straw hat. 

The feet should always be warm and dry, the shoes worn in wet weather 
being water-proof ; and special care should be taken in the selection of 
shoes, that they be pliable and loose, so as to allow freedom of growth, 
without compression of any part. If during the period of growth proper 
precautions are taken in this respect, the chiropodist would have little to 
do in subsequent years. Corns, bunions, and in- growing toe-nails origi- 
nate from shoes hard and unyielding, or too tightly fitting. 

Sleep. 

The new-born infant requires from fifteen to eighteen hours' sleep each 
day. If it do not have this, and be wakeful, it is probably not well. 
It sleeps therefore most of the time when not awake for nursing, bath- 
ing, and change of clothing. As it grows older, a less and less amount 
of sleep is required. At the age of three years, about nine hours of 
sleep are needed, and it is better, in my opinion, for healthy develop- 
ment, to allow children of this age one or two hours of sleep in the 
middle of the day. They indeed often take it by falling asleep on 
the sofa, or floor, or in places where they are liable to take cold through 
currents of air and scant covering, if not heeded. 

Much harm has been done to children who were wakeful by nurses, 
and mothers too, who have given them active and dangerous drugs, as 
laudanum or morphine, under some enticing name as soothing syrup or 
cordial. A wakeful and fretful child is not well. Its ailment may be 



72 BATHING, CLOTHING, SLEEP, EXERCISE. 

trivial or grave, but it should never, under such circumstances, receive 
from mother or nurse any of those proprietary mixtures, having seductive 
names, which the shops contain. If it need medicine, it should be ex- 
amined and prescribed for by the physician. It is scarcely necessary to 
call attention to some accepted and important facts regarding the dor- 
mitory of children. A free ventilation is required, either through ventila- 
tors or open windows, and a sufficient number of cubic feet of air should 
be allowed for each sleeper. A small room should not contain more than 
two children. Curtains should not as a rule be employed, and no open 
vessels of foul water should stand in the room, or anything else which 
may contaminate the air. The garments worn through the day must be 
entirely removed and hung up away from the bed. 

In the asylums of New York, where from long and abundant experi- 
ence the management of children is systematized, infants and the younger 
children are usually put to bed between six and seven, and the older chil- 
dren between seven and eight o'clock ; the last meal or supper, as I have 
stated elsewhere, being light and easily digested. 

Exercise. 

Exercise is an important hygienic requirement. Harm often results 
from modes of exercise which are not adapted to the age. Occasionally 
I meet cases of permanent bow r -leg, which have manifestly resulted from 
attempts to make the infants stand at the age of four or five months. 
They should never be encouraged to w r alk or stand till about the age of 
one year, and if they do at the age of nine or ten months let it be volun- 
tary, and not taught by standing them upon their feet. In case of infants 
with rachitis, which disease is common in the cities, and is characterized 
by a lack of lime- salts in the bones, and can be detected by great back- 
wardness in teething, attempts to stand or walk for any length of time 
should be discouraged, till by the use of lime-salts and cod-liver oil, and 
improvement of the general health, the rachitis is cured. Much of 
the permanent deformity which mars the beauty and symmetry of adult 
life originates in rachitis and might have been prevented. 

The infant before he is old enough to stand takes sufficient exercise in 
a way that is natural and harmless. Let him lie upon his back in the 
crib, or on the floor, with a blanket under his body and a pillow under his 
head, and all his clothes loose, so as not to restrain the free movements 
of his limbs. A healthy infant seems to enjoy this attitude, moving all 
his limbs sufficiently to give them the required exercise, and evincing his 
delight and exuberance of life by utterances which are as expressive as 
words. 

In the cool months of our latitude, infants should not be taken out-doors 
until the age of three months, and then only for a brief time in the 
warmest part of the day ; but in the summer they should begin to receive 



EXERCISE. 73 

out-door air and exercise at the age of one month. In warm weather 
the face should never be covered by a vail or otherwise, and air and light 
should have free access to it. The rays of the sun, however, from a clear 
sky, should be excluded either by a parasol or the shade of trees or houses, 
or by the carriage in which the infant is carried. In cold weather, or 
when there is a strong wind, the protection of a vail is needed. Rude 
tossing of infants, which is common in families, should always be forbid- 
den. Its effect on the cerebral circulation is likely to be bad, and it 
involves risk of a serious accident. In one instance to my knowledge, 
death resulted from injury received in this way. 

"Walking, as it is the natural, so it is the best, exercise for the older 
infants and during the period of childhood. It promotes digestion when 
not carried to the extent of fatigue, and gives gentle exercise to all the 
muscles. The baby-carriage answers a useful purpose, when combined 
with walking. ^Vith the ordinary hired nurse it is safer for the infant to 
be taken out in this vehicle than in the arms, for if the nurse in careless 
walking should trip, great harm might result. In one instance which 
came under my notice convulsions and idiocy were plainly referable to the 
fall of an infant from its nurse's arms upon its head. 

The ordinary lawn sports of childhood, as croquet for both sexes, play- 
ing ball or quoits for boys, which are rendered more exciting by the 
spirit of rivalry, arc also useful for muscular exercise and development, 
while they involve little danger. The swing affords a pleasant exercise, and 
with the propulsion required it gives gentle but efficient activity to most 
of the muscles. 

Many of the gymnastic exercises are too severe, involve too much risk of 
ruptured tendons, sprained joints, and even of dislocated or broken 
limbs. 

Among all the ingenious inventions to provide sports and pastimes 
for children, there are none better than gardening and farming, where 
facilities will allow it, conjoined with the ordinary household duties. The 
healthy and robust development of the farming population, their almost 
complete immunity from rachitic and scrofulous ailments, is attributable 
to their out-door mode of life, and the many kinds of healthful work 
which farm life requires. Such work is always in the highest degree 
beneficial for children old enough to participate in it, while it develops 
the habit of productive industry. 



74 APN(EA NEONATI 



CHAPTER X. 

ACCIDENTS AND AILMENTS INCIDENTAL TO THE BIETH OF THE 
INFANT, AND DETACHMENT OF THE COED. 

Apncea (Asphyxia) Neonati. 

In the healthy infant, born under favorable circumstances, the two 
important functions of life, respiration and circulation, arc established 
within the first minute. But it not infrequently happens, in consequence 
of some unfavorable circumstance, that the heart and lungs cease to act, 
and the infant at birth lies motionless as one dead. Sometimes in these 
cases an occasional pulsation of the heart can be detected when the finders 
press under the left ribs, but there is no respiration. According to the 
nature of the cause, the surface is exsanguine or cyanotic and livid. 

Causes. — These are various. The fault may be partly in the infant ; 
it may be feeble in its development ; but the common causes are com- 
pression of the cord during birth, from breech presentation or otherwise ; 
powerful, frequent, and long-continued uterine contractions, often induced 
by ergot, but sometimes occurring normally, which compress the placenta, 
and consequently obstruct the foetal circulation ; detachment of the 
placenta before birth, and protracted labor, from pelvic malformation or 
otherwise, even when there is no unusual severity of the pains. 

Treatment. — Obviously the treatment must be prompt. Mucus should 
be removed from the mouth and fauces with the finger, and except in 
those cases in which there has been placental haemorrhage or anaemia 
from other causes, as exhibited by pallor of the surface, a few drops of 
blood should be allowed to run from the cut extremity of the cord. The 
flow induced, aids in establishing the circulation, and, in the large propor- 
tion of cases, in which there is congestion of the internal organs, gives 
partial relief to it. Brisk rubbing of the body, slapping the buttocks, 
blowing in the face, sprinkling water upon it, alternately transferring the 
body from a tub of hot to cold water, may be tried in quick succession, 
and, if there be no signs of returning animation, no time should be lost 
in resorting to artificial respiration. 

The child should be placed on its side upon the edge of a table, with a 
blanket underneath it, and the head in such a position that the epiglottis 
falls forward ; a towel or napkin should be placed over its face, having a 
hole of sufficient size to blow through, corresponding with its mouth. The 
physician, compressing firmly the epigastrium with his thumb, blows a full 



APXfflA NEONATI. 75 

breath through the hole. A little of the air, notwithstanding the com- 
pression, enters the stomach, some may escape by the nostrils, and the 
rest enters the lungs. Immediately, the hand passing from the epigas- 
trium to the thorax, compresses it gently, though with sufficient force to 
produce expiration. This should be repeated six or eight times per 
minute. The action of the heart, previously slow, becomes quicker by 
the artificial respiration. I have been able to produce pulsations by this 
method when the heart had ceased to beat for a considerable time, and 
death, to all appearance, had occurred. Some recommend placing the 
infant on the right side, on account of the position of the valve between 
the auricles, but I think it is better to change it from one side to the 
other, in order to prevent congestions, which are so apt to occur when 
the circulation is imperfect. The circulation always commences sooner 
than respiration. The first respirations are mere gasps, not more than 
one or two per minute in cases of decided asphyxia, but as they become 
more frequent, they are also deeper. 

Artificial respiration should be continued fifteen or twenty minutes in 
cases, in which no action of the heart can be detected, by pressing the 
fingers under the ribs, when, if there be no signs of returning animation, 
the case is hopeless. If there be any pulsation, however feeble, we should 
not cease in the attempt at resuscitation. Some prefer insufflation through 
a tube (as the segment of a catheter) introduced into the larynx, and 
pressure upon the thyroid cartilage so as to close the pharynx, instead of 
upon the epigastrium. The principle of treatment is similar, but the mode 
which I have recommended above I have found successful beyond ex- 
pectation. Thus, in one case in my practice in which pulsation in the 
umbilical cord had ceased from ten to fifteen minutes before birth in con- 
sequence of its prolapse, I employed artificial respiration nearly a quarter 
of an hour before there was any appreciable pulsation, but by persever- 
ance the circulatory and respiratory functions were fully re-established, 
and the child lived and was vigorous. When respiration commences, in- 
sufflation may cease, but it is proper to aid the respiratory movements a 
little longer by compressing the thorax after each inspiration. Still, the 
physician may be disappointed in the result. In not a small proportion 
of cases the respiration continues gasping, and after a few hours, perhaps 
even a day, death ensues. I have made post-mortem examinations of sev- 
eral infants who have died under such circumstances, chiefly in the 
Nursery and Child's Hospital, about six from recollection, and have found 
considerable uniformity in the appearance of the viscera. Only a small 
portion of the lungs, sometimes almost none at all, was found inflated, 
even when the cries had for a time been strong, and extravasated blood, 
usually in considerable quantity, lay upon the surface of the brain, evi- 
dently having escaped from the meningeal vessels, which were in a state 
of extreme congestion in consequence of the protracted or difficult birth. 



70 CAPUT SUCCEDANEUM. 

Meningeal apoplexy, therefore, seems to me the chief cause of the ill suc- 
cess attending our efforts to save those who are so far resuscitated, as to 
be able to breathe. 

Recently, Professor H. L. Byrd, of Baltimore, has recommended a 
simple mode of resuscitation. The physician places his hands under the 
middle portion of the back of the child, with their ulnar borders in con- 
tact, and at right angles to the spine. Extending his thumbs, he carries 
forward the two extremities of the trunk by gentle but firm pressure, so 
that they form with each other an angle of about 45° in the diaphragma- 
tic region. Then the angle is reversed by carrying backward the shoul- 
ders and the nates. An assistant may aid by supporting the head. By 
alternating these movements, Professor Byrd has succeeded in effecting 
resuscitation when other methods had failed, and when so much time 
had elapsed that the case w T ould seem hopeless to most practitioners. 
The name and position of Dr. Byrd commend this method to considera- 
tion and trial. (American Supplement of Obstet. Joum. of Great Britain 
and Ireland, 1873.) 

Caput Succedaneum — Cephalaematoma. 

During the birth of the child, extravasation of blood not infrequently 
occurs in the part of the scalp which presents. This results from the 
passive congestion, more or less intense according to the duration of labor 
and severity of the labor-pains, which occurs in the presenting parts, 
whether scalp, arm, or breech. Caput succedaneum is the term em- 
ployed to designate the swelling thus caused. Its seat is the loose con- 
nective tissue of the scalp external to the pericranium. The tumor is 
soft, painless, and usually located upon the occiput. It consists partly of 
extravasated blood, but largely of serum which has transuded from the 
congested vessels before that degree of congestion was reached, required 
to effect the transudation of the corpuscles. I have repeatedly had an 
opportunity to examine this tumor in stillborn infants brought from the 
lying-in wards attached to the Xursery and Child's Hospital, and have 
found when it was slight that it consisted almost entirely of serum, but 
ordinarily when dissected it presented the appearance of a bruise, with a 
large proportion of serum, the blood and serum infiltrating the scalp to a 
greater or less distance beyond the appreciable limits of the tumor. 
Caput succedaneum requires no treatment. As it lies in the loose con- 
nective tissue of the scalp, its liquid permeates the open connective tissue 
in every direction, and is rapidly absorbed, while the tumor disappears. 
The subsidence of the swelling is usually complete within forty-eight 
hours. 

Occasionally blood is extravasated under the pericranium, detaching it 
from the bone. This occurs in connection with caput succedaneum, and 
is observed when the latter declines. The tumor thus produced is desig- 



OPHTHALMIA NEON ATI. n 

nated cephalhematoma. It is situated upon the occipital or parietal bone, 
near the posterior fontanelle. Its base, corresponding" with the denuded bone, 
is circular or oval, and it rarely crosses a suture. In exceptional instances 
two cephalaematomata occur, located upon the occipital and one parietal 
or upon both parietal bones. The liquid, being surrounded by the firmly 
attached pericranium, does not escape into the surrounding tissues, as oc- 
curs in caput succedaneum, and is therefore more permanent. The tumor 
flattens slowly, and does not disappear till after several weeks. At the 
age of six months a slight prominence can sometimes be detected, indi- 
cating the seat of the tumor. As the pericranium elevated by the blood 
does not lose its vitality, it soon begins to produce bone, so that after 
some days a ring of new bone can be detected by the finger surrounding 
the base of the tumor, and on the inside of the detached membrane, a 
layer of bone is produced, thin at first and flexible, but gradually approxi- 
mating the old bone, and becoming firmer as absorption occurs. 

Some time since, a specimen was presented by me to the New York 
Pathological Society, showing this accident and the mode of cure. The 
child died about two months after birth, and the blood constituting the 
tumor, which had been in great part absorbed, was completely incased by 
the old bone below and the new thin formation above. The cavity at 
length becomes obliterated, and there onlv remains some thickening of 
that part of the cranium which corresponds with the location of the tumor. 



CHAPTER XI. 

OPHTHALMIA NEONATI. 

This disease occurs in two forms, namely, the catarrhal and blennorhoeal, 
and there are many cases which are intermediate. 

Causes. — These arc not the same in all cases. Exposure of the in- 
fant's eyes soon after birth to a bright light, catching cold, the introduc- 
tion of a little of the vernix caseosa under the eyelids in the first washing, 
smoke, dust, and irritating gases, coming in contact with the eyes are 
recognized causes. Infants living in ill- ventilated and dirty apartments, 
having untidy clothing, with faces and bodies seldom properly washed, 
and attended by dirty nurses, are more frequently affected than those in 
the better walks of life, and better cared for. The disease is more preva- 
lent in asylums than in private practice, for in the former the anti- 
hygienic conditions, which conduce to it, more frequently abound. 

Blennorrhceal ophthalmia has been known to occur during epidemics 
of puerperal fever, probably from the epidemic influence, but a common 
cause is the introduction of a particle of infective matter under the lids 



78 OPHTHALMIA NEON AT I. 

daring birth, or subsequently by careless handling. But blennorrhoeal 
ophthalmia is in a considerable proportion of cases produced by the action 
of those common non-infectious causes which have been mentioned 
above, and which in other cases produce a simple catarrhal inflammation. 
Why there is this difference in the effects of these non-specific causes is 
not known. In most cases ophthalmia neonati begins soon after 
birth, namely, by the third or fourth day, but it may not begin till in 
the second or third week. 

Symptoms. Blennorrhoeal Form. — In the beginning the palpebral con- 
junctiva is observed to be red, a little swollen, and its cutaneous surface 
presents a faint reddish tinge. Light appears to be gainful, and the 
child is fretful and sleeps but little ; but the eye itself has its normal ap- 
pearance. The progress of the disease, however, is rapid, and in twenty- 
four or thirty-six hours there is so much tumefaction that the upper lid 
extends over the lower, and it may be impossible to separate them suffi- 
ciently to obtain a view of the eye. The tumefaction is due to cedematous 
infiltration. The conjunctiva, both palpebral and ocular, now presents a 
deep red hue, is thickened and swollen, and numerous fine granulations 
appear upon it ; occasionally also flakes of very delicate pseudo-membrane 
can be observed in addition. There is an abundant production of pus of 
a creamy appearance, sometimes tinged with blood, which oozes out 
when the lids are separated. A critical period has now arrived, one 
which may involve the destruction of the cornea unless the case be 
promptly and judiciously treated. Indeed, the gravity of the disease 
relates chiefly to the state of the cornea, which up to the present time, 
notwithstanding the severity of the inflammation and the amount of sur- 
rounding infiltration, has remained transparent and apparently unaffected. 
But within another twenty-four hours the cornea may lose its polish, and 
grayish, opaque spots of softening appear upon it. Soon perforation 
occurs, the aqueous humor escapes, and the iris falls forward, closing the 
aperture and preventing further loss of the liquids of the eye. 

I have observed destruction of the cornea and loss of sight chiefly, 
first, in cases of true gonorrhoeal infection, in which there is the maxi- 
mum amount of inflammation and tumefaction, extending even over th>e 
malar bone and supraorbital ridge, with marked redness and elevation of 
temperature of the lids : and, secondly, with a less degree of inflamma- 
tion in those who were highly scrofulous. Attention, then, to the cornea 
is all-important, since it can usually be saved with proper treatment, 
although there may be so much purulent discharge and oedema that it may 
be impossible to see it for several days. Occasionally the cornea, instead 
of sloughing, becomes infiltrated to a greater or less extent, and ulcerates, 
but without perforation. As the patient recovers, cicatrization occurs. 

The inflammation soon begins to decline. The swelling, heat, and 
redness of the lids and conjunctiva, and the granulations, gradually disap- 



OPHTHALMIA NEONATI. 79 

pear, and recovery is complete, except so far as the cornea may have heen 
injured. 

Catarrhal Form, — The inflammation is from the first of a mild grade, 
pertaining chiefly to the palpebral conjunctiva, with but a slight discharge 
of purulent matter, and with little swelling or increase of heat in the 
lids. Attention is directed to the complaint chiefly by the secretion 
which collects in the angles of the lids or upon their border. There may 
be slight intolerance of light, and ordinarily minute granulations appear 
upon the inflamed mucous surface. This form of the disease may disap- 
pear within a few days, or it may be protracted. 

Ophthalmia of the new-born is contagious, sometimes highly so. It 
commences on one side, and, without precautions, commonly within a 
few days extends to the other. 

Treatment. — As soon as the inflammation occurs, the opposite sound 
eye should be covered with a compress, kept in place by strips of adhe- 
sive plaster. This eye should be examined, however, once or twice daily, 
in order to detect the commencement of inflammation, and the bandage 
reapplied. 

Catarrhal ophthalmia requires very simple treatment. Frequently bath- 
ing the lids with lukewarm water, or milk and water, so as to remove the 
secretion from between the lids, suffices in a large proportion of cases. 
In the severer cases, lead- water constantly or frequently applied to the 
exterior of the lids is useful. Among the poor, mothers ordinarily bathe 
the lids with breast-milk, and by this simple treatment effect a cure. If 
the inflammation should not abate soon by this treatment, a mild collyrium 
of one fourth grain of nitrate of silver to one ounce of water should be 
applied between the lids and allowed to run under them. 

Blennorrhceal ophthalmia, on the other hand, requires prompt and 
judicious management. There is scarcely a disease in which delay is more 
disastrous. 

The frequent removing of the pus is very important, which is confined 
in large quantity underneath the closely compressed lids, and by its pres- 
sure and irritation increases greatly the danger of destruction of the 
cornea. Therefore the lids during the height of the inflammation should 
be pressed apart every hour, so as to allow the pus to escape, and the 
space between the lids be freed from pus by a camel-hair pencil or a 
pledget of finely picked lint. Occasionally warm water may be thrown 
under the lids by a small glass syringe, to wash away pus and any flakes 
of pseudo-membrane. Probably two or three drops of carbolic acid to 
each ounce of water would be beneficial, from the known good effect of 
this agent on suppurating surfaces, but I have never employed it. 

Medicinal applications to the inflamed conjunctiva should, in most cases, 
be mild, but should be frequently applied. I have used, in the treat- 
ment of purulent ophthalmia, as recommended by Professor Gross, a weak 



80 OPHTHALMIA NEONATI. 

solution of corrosive sublimate applied every three hours between and 
under the lids, the pus, so far as practicable, having been first removed 
by the brush and syringe. The following is the formula, and the result 
has ordinarily been favorable : 

3. Hyd. chlor. corros., gr. j; 
Aquae rosae, 3 ij ; 
Aquae, 3* vj. Misce. 

Still the beneficial result which I have observed from this collyrium, 
was no doubt largely due to the frequent removal of the pus, the impor- 
tance of which cannot in my opinion be too strongly urged. In blen- 
norrhceal ophthalmia, during the active period of the inflammation, with 
hot and swollen lids, a single thickness, or two thicknesses of linen, 
squeezed out of ice-water, and renewed every two or three minutes 
when they begin to warm, aids materially in subduing the inflammation, 
every moment of which, when the lids are much swollen, involves danger 
to the delicate cornea. This measure, therefore, which requires diligence 
on the part of the nurse, should be insisted on. As long as the cornea 
retains its transparency and polish, the eye is safe, but, as stated above, 
it is often difficult to obtain a view of it for some days. 

The decline of the inflammation is gradual, but generally pretty rapid, 
yet several weeks may elapse before there is full restoration to the normal 
state. When the inflammation begins to abate, and the dangerous tume- 
faction has to a great extent subsided, a collyriam of one fourth grain of 
nitrate of silver to the ounce will expedite the cure. 

Occasionally granulations remain upon the lids. If they do not dimin- 
ish and disappear when the purulent inflammation has ceased, I would 
not practice excision, as recommended by Vogel, but, having everted the 
lids, apply a solution of nitrate of silver, five or ten grains to the ounCe, 
to the granulations, each second day, and immediately wash away the 
solution by a camel-hair pencil with salt and water, and apply a little 
sweet oil before the lid is returned. If the granulations do not disappear 
with this treatment, they may be lightly touched with the smooth surface 
of a crystal of sulphate of copper, followed by the application of water 
and sweet oil. By this mode of treatment, employed from the com- 
mencement of the inflammation, a large proportion even of the severest 
cases do well. 

Doctor 0. D. Pomeroy, the experienced oculist, has kindly favored me 
with the following remarks relating to the treatment of this disease : 

" The first indication of treatment is thorough cleanliness. The eyes 
should be washed out with tepid water, and salt — a drachm to the pint. 
This may be done every one, two, or three hours, according to the 
amount of discharge. The latter never should be allowed to remain in 



OPHTHALMIA NEONATI. 81 

contact with the cornea long at a time, on account of its excoriating 
effect. A soft, old linen rag or a soft sponge may be used to apply the 
salt water : an assistant separates the lids and the water is squeezed out 
of the sponge into the eye. A syringe is objectionable on many ac- 
counts ; one being that the poisonous matter may be thrown against the 
operator's eyes. Frequently the discharge may roll into stringy masses, 
requiring them to be wiped away by means of the soft rag. 

" If the attack be mild, I would be very slow to order astringents or 
stimulants. Atropine, one grain to the ounce, used three or four times daily, 
must always be prescribed in any case whatever, for the corneal lesions 
are the only ones we fear. Acid carbol., two to four grains to the ounce, 
may be used several times a day with a view to gently stimulate the 
conjunctiva and destroy the poison. Binding up the sound eye is not 
much practised in infants ; it is difficult to keep the dressing on, and it 
does not always protect the eye ; further, the second eye involved is not, 
as a rule, as bad as the first one. After three or four days, if the dis- 
charge become very profuse, and the tissues have a relaxed look, astrin- 
gents should be prescribed, but they should never increase the irritation, and 
should decrease the discharge. Arg. nit., gr. ss. to the ounce, may be used 
from two to four times daily. Aluminii et potas. sulph. , gr. iv. to the ounce, 
may be employed for the same purpose, very freely. Zinc, sulph., gr. j 
to the ounce, may be also used in a similar manner. After a week or ten 
days, if the lids still remain swollen, and there be a profuse discharge, the 
lids may then be everted and stronger applications made. Arg. nit., 
five to ten gr. to the ounce, may be brushed on every second day ; care- 
fully wash with salt and water before returning the lid to its natural posi- 
tion. Alum in saturated solution may be used in a similar manner, or 
acid, tan., gr. xx. to the ounce, or cupri. sulphat. in ten gr. solutions. 

" If the remedy do good to the eyes, continue ; if not, change to some- 
thing else, and do not, on any account, over-irritate the eyes. 

" Cold may he applied in the earlier stages with tense, red, and swollen 
lids, and insufficient discharge, for one, two, or three days. 

u The rule is to use the cold sufficiently to keep down any excess of in- 
flammatory action. This may be known by diminished redness, heat, and 
swelling, and improvement in the appearance of the discharge. Cold 
applied about half the time is a good rule ; for instance, keep it on from 
fifteen minutes to an hour, then leave it off for the same time ; be guided 
by the exigencies of each case. Scarification of either the ocular or 
palpebral conjunctiva may be performed if necessary in the earlier stage 
if there be much swelling. The source of the injury to the cornea is 
from interference with its nutrition in consequence of compression and 
retarded circulation of the conjunctival and episcleral vessels, caused by 
the swelling. In scarifying the ocular conjunctiva, the incision should 
radiate from the corneal margin outward, and should not be deep, but 



82 OPHTHALMIA NEONATI. 

enough to cause pretty free bleeding. This should be encouraged by 
bathing with warm water. 

" When the cornea is threatened with necrosis or sloughing, we may meet 
the indication as follows : the scarification already mentioned exerts a 
favorable influence, but if the lids be much swollen, perhaps impossible 
to evert, and likely enough in a spasmodic condition pressing upon the 
cornea, we may perform a canthotomy, that is, pass a stout pair of scissors 
into the external canthus and divide the commissure by one resolute cut 
extending to the bone. The bleeding resulting is of service, but the 
power of the orbicularis to exert pressure on the eyeball is temporarily 
broken, which is the main indication for the operation. The cornea 
should be carefully observed daily to see that there is no haziness or com- 
mencing ulcer, or even any abrasion of the epithelium, for the latter is 
often the first sign of a commencing ulcer. 

" In case the cornea be seriously involved, especially if the eyeball be 
too hard or tender to the touch, and the patient be suffering unusual 
pain, paracentesis of the cornea should be performed. Unless the operator 
be very skillful, a spring speculum should be used and a fixation forceps 
to keep the eye steady. The cornea should be pierced near its periphery, 
and the broad cataract needle should be passed into the anterior chamber 
with its point well turned forward to avoid the lens. In this position it 
should be gently tilted, so as to make the wound gape, when the liquid 
slowly escapes ; hold in this position until most of the fluid is evacuated, 
then withdraw the needle slowly to prevent prolapsus of the iris. This 
operation may be repeated every day or two if necessary. In an epi- 
demic of purulent ophthalmia in young children, at the New York Found- 
ling Asylum, I at first had a few cases of perforated cornea, but being 
more on my guard, I examined subsequent cases very carefully ; when 
on the first signs of corneal trouble I performed paracentesis and did not 
afterward have a single perforation. However, the most careful attention 
will not always prevent trouble. One day you ma) 7- find the patient doing 
well, and on the next the cornea maybe perforated. It is well to remem- 
ber that this is a very fatal form of eye disease. 

"Abstraction of blood by leeches may also be practised. As a rule, how- 
ever, this is not very frequently employed in young children. One leech 
may be used at about one inch from the external canthus, but frequently 
it should be removed before wholly filling, and the resulting haemorrhage 
may be stopped by pressure or styptics. Repetition of the leeching is 
rarely required ; but the leech may be applied again in twenty-four hours 
if the hyperaemia return. A membrane sometimes forms on the con- 
junction of the lid or globe, or both, which may or may not be true 
diphtheritic conjunctivitis. It is an open question where membranous 
conjunctivitis ends, and diphtheritic conjunctivitis begins. In either 
event stimulating applications must be interdicted, at least until the mem- 



INFLAMMATION OF THE UMBILICAL VEIN. 83 

brane becomes thrown off. In other respects the treatment is similar to 
what has been already laid down. In Europe diphtheritic conjunctivitis 
is very fatal to the eye. In this country, for some reason not well known, 
it does not seem to be so fatal, although in a bad case here the eye is 
usually destroyed. When the eyes have nearly recovered from acute at- 
tack, a chronic conjunctivitis may result, even passing into a granular 
conjunctivitis or a true trachoma, when stimulating applications to the 
lids may be used, including atropine drops as a coltyrium if there should 
be any photophobia or corneal trouble. If the child be of good consti- 
tution, however, and the general health be carefully preserved, this latter 
sequel to the disease does not often occur. ' ' 



Chapter xii. 

DISEASES OF THE UMBILICUS. 

When properly managed, the cord desiccates and falls off between the 
third and ninth days. The nurse should not be allowed to oil it, which 
she will sometimes do unless forbidden, as this retards desiccation. If 
the dressing of the cord be allowed to remain wet from the urine or other- 
wise, it does not desiccate, but decomposes. This is not infrequent 
in poor, intemperate, and slovenly families. The decaying cord is 
apt to produce inflammation of the navel. Some Southern physicians, 
prior to the late war, attributed the prevalence of trismus neonatorum 
among the slaves to the lesion of the navel produced by this cause,. the 
trismus being then essentially traumatic. 

Inflammation of the Umbilical Vein and Arteries. 

When the cord is ligated at birth, if the child be in its normal state, 
clots form in the umbilical vessels from the navel inward. Atrophy of 
the vessels follows, and by the twenty-fifth day they are represented by 
small, firm, fibrous cords. Sometimes, though rarely, a true phlebitis or 
arteritis occurs in these vessels in the first days after birth, due either to 
the low vitality of the child, and decomposition of the fibrinous plugs and 
gelatinous substance of the cord, or to the entrance into the vessels of puru- 
lent or decaying matter from the fossa of the umbilicus. We are some- 
times able, by pressing along the abdominal walls toward the umbilicus, 
to squeeze out a few drops of the decaying and purulent substance. The 
navel itself is usually inflamed at the same time. This is a very serious 
disease. Pus, with particles of disintegrated fibrin, is apt to pass along 
the vessels and enter the circulation, and, being intercepted in distant 



84 DISEASES OF THE UMBILICUS. 

parts, give rise to embolismal inflammations. In this manner, prob- 
ably, several distinct subcutaneous inflammations and nodules of embo- 
lismal pneumonitis occurred in a new-born infant, which I attended in 
1868. The infant belonged to a family highly scrofulous and prone to 
scrofulous inflammations. Umbilical phlebitis and arteritis are said to 
occur most frequently in lying-in institutions, during epidemics of puer- 
peral fever. 

Treatment. — In the manner already indicated Ave should attempt to 
press out gently any purulent and decomposing substance from the vessels, 
and the infant should be placed with its abdomen dependent, so far as it 
can be done without rendering it uncomfortable, so as to aid in the escape 
of the liquids by gravitation. The umbilical fossa should be kept clean, and 
warm water containing a little carbolic acid may be dropped upon it 
several times daily. The abdomen should be covered with a soft and 
warm poultice. 

Inflammation and Ulceration of Umbilicus. 

Inflammation of the umbilicus sometimes occurs in the new-born about 
the time of the detachment of the cord, or soon after. It probably results 
from uncleanliness, or carelessness in the management of the cord, by 
which irritating and decomposing substances remain in the umbilical fossa. 
Sometimes decomposing particles from the cord are the probable irritant. 
This disease is also most apt to occur in cachectic infants, or those of 
scrofulous parentage, whose general condition ^renders them liable to 
inflammations. The umbilicus becomes red, slightly swollen, and moist 
by a secretion. Often the inflammation remains two or three days in this 
mild form, receiving no treatment except from the nurse, and disappearing 
by the use of the dusting-powder, as lycopodium, which she employs. In 
other instances, it extends over a radius of an inch or even more, the walls 
of the umbilicus become swollen and infiltrated, and ulceration suc- 
ceeds. The ulcer is circular, occupying the site of the navel, and is at- 
tended by a purulent discharge. The inflammation may now gradually 
abate, and the ulcer heal with a cicatrix in place of the umbilicus. But 
in other instances, especially if there be decided cachexia, the ulcer ex- 
tends in breadth and width, till finally, in the worst cases, the peritoneum 
becomes involved, and perforation or peritonitis occurs, with death. 

Under unfavorable hygienic circumstances the blood of the infant being 
vitiated, the ulcer may become gangrenous, or the inflammation may ter- 
minate directly in mortification, without the formation of an ulcer. In 
either case the prognosis is unfavorable. If a dark-brown slough occu- 
py the site of the umbilicus, and a sero-sanguineous discharge exude 
from underneath, the common result is perforation, peritonitis, and death 
in from one to two weeks. 

Treatment. — Inflammation of the umbilicus, if severe, and espe- 



UMBILICAL HEMORRHAGE. 85 

cially if attended by destruction of the tissues involved, rapidly reduces 
the strength. In such cases four or five drops of brandy should be ad- 
ministered every hour to two hours in the breast-milk. 

In the simple inflammation the navel should be bathed with lukewarm 
water three or four times daily, and the ointment of the oxide of zinc be 
constantly applied; or if there be little or no discharge, the navel may 
be dusted with the powdered bismuth. In case of ulceration the navel 
should be gently washed three or four times daily w T ith lukewarm water, 
to which carbolic acid is added — three or four drops to the ounce ; and if 
there be much inflammation, a light poultice of pulverized slippery elm 
should be applied in the interval, or if the inflammation be moderate, the 
balsam of Peru. If gangrene supervene, the parts should be frequently 
bathed with the carbolic-acid-water, and a cloth soaked with it be applied 
over them. The slough should be detached as soon as it is so far separated 
that its removal causes no hemorrhage, after which the treatment for ulce- 
ration is appropriate. 

Umbilical Granulations or Fungus. 

When the cord falls, granulations sometimes sprout out from the ex- 
posed raw surface, and complete cicatrization is impossible till they are 
removed. They form a rounded mass of a pale reddish hue, at the centre 
of the umbilical fossa, bleeding when rubbed, and causing constant moist- 
ure of the umbilicus. The largest which I have seen had perhaps twice 
the size of a large pea, and they may be of any smaller size. 

Treatment. — By pressing upon the umbilical parietes the tumor rises 
from the fossa, so that a silk ligature can be applied around its base, 
when the mass can be readily removed with the scissors. If the gran- 
ulations be small, they may be removed by the scissors without the 
ligature, and haemorrhage prevented by touching the surface with lunar 
caustic. 



CIIAPTEE XIII. 

UMBILICAL HEMORRHAGE. 

The granulations which have been described above occasionally cause 
considerable haemorrhage when injured. The profuse and even fatal haem- 
orrhage which occurs at birth, or soon after, from too loose a ligature of 
the umbilical cord, or from laceration or other injury, is so well known, 
and its cause so apparent, that it need only be alluded to in this connec- 
tion. Bouchut details a case in which death occurred even before birth, 
from this form of haemorrhage. The child w T as attached to the placenta 
by a very short cord, which prevented delivery till it parted by the trac- 



31) UMBILICAL njJMOKRHA'GB. 

tion of the forceps. TJie bleeding from the umbilical vessels was so 
profuse, that the child was pallid and lifeless when born. 

There is another form of umbilical haemorrhage, cases of which have 
been from time to time observed for more than a century (one of the first 
on record was reported in the Gentleman'' 8 Magazine, April, 1*752, by Mr. 
Watts, a physician in Kent, England), but little was done to- elucidate its 
nature till three American physicians made it the subject of careful study, 
and the monographs which they have published upon it arc the best which 
the literature of the profession affords. Dr. Francis Minot read his paper, 
containing the statistics of 46 cases, before the Boston Society for Medi- 
cal Improvement, in April, 1852. Prof. Stephen Smith prepared his 
paper, containing the statistics of 79 cases, for the New York Statistical 
Society, in 1855. It was published in the New York Journal of Medi- 
cine for that year. Dr. J. Foster Jenkins presented his monograph as a 
report to the United States Medical Association in 1858, and it was pub- 
lished in the Transactions of the Association for that year. This paper is 
very valuable on account of its statistics, as the writer succeeded in col- 
lecting the records of 178 cases from medical journals, and gentlemen of 
the Association. These three papers contain nearly all that is known in 
reference to this disease. 

Sex — Age. — Females arc less liable than males to this haemorrhage. In 
Jenkins's cases, 34^ per cent, were females, 65| males. The following 
table gives the age at which the hemorrhage commenced in 99 cases : 

AGE. NOS. 

Under 1 day, 5 

Under 2 days, 7 

Under 3 " G 

Under 4 " 3 

5 to 7 " (inclusive), 32 

8 " 10 " " 25 

11 " 15 " " 16 

16 " 21 " " . 4 

56 " 1 

99 

Ordinarily the bleeding commenced very soon after detachment of 
the cord, but in not a few the cord was still adherent. 

Causes. — The common proximate cause is feeble coagulability of the 
blood. In the normal state, when the cord is ligated, the fibrin of the 
blood, which now ceases to flow in the umbilical vessels, forms coagula 
so firm that, by the time the cord is detached, haemorrhage is impossible. 
But in the majority of those affected with this disease, the clots are so 
soft and loose that they do not present any effectual barrier to the pres- 
sure of blood, which therefore oozes through them or presses them away. 
This lack of coagulability is easily demonstrated, for if a little blood, as 



UMBILICAL HEMORRHAGE. 87 

it escapes, be caught in a vessel, it will be found to remain liquid a long 
time. This dyscrasia, or morbid state of the blood, which we therefore 
recognize as a chief cause of the haemorrhage, does not have the same 
origin in all cases. It is sometimes due to inherited syphilis. The infant 
affected with it may be plump, and appear well at birth, but in most 
instances, when the haemorrhage is to occur, it is puny and cachectic, ex- 
hibiting also local manifestations of the disease with which it is affected. 
Thus, in a case in my practice, the infant, puny, and apparently born 
before term, was observed to have several blebs of pemphigus on the first 
day, from some of which blood soon began to ooze, but the fatal umbili- 
cal haemorrhage did not commence till after two weeks. 

In about one-fifth of the cases ecchynioses or petechioe have been 
observed upon various parts of the surface, affording additional proof of 
the general blood disease. 

Jaundice is another cause of impoverishment of the blood in the new- 
born, and therefore of umbilical haemorrhage. The writers who have col- 
lected records of the haemorrhage, all remark the frequent occurrence of 
the icteric hue, both before and during the bleeding. It is not improb- 
able that, in certain instances, the jaundice is hematogenous, arising from 
destruction of the red corpuscles and liberation of the luematin, a not un- 
usual result of a prof ound dyscrasia, whether syphilitic or originating from 
some other cause. But in other, and probably most instances, the jaun- 
dice proceeds from the liver, and is the cause of the change in the blood. 
Thus, in five of Jenkins's cases, there was occlusion of the hepatic or 
common bile-ducts, and jaundice, from the presence of biliary acids in 
the blood, causes diminution in the amount of fibrin and red corpuscles. 
In the ordinary form of icterus neonatorum, the cause of which is found 
in the relative fullness of the capillaries and minute bile-ducts in the acini 
of the liver, the coagulability of the blood must evidently be impaired in 
proportion to the degree and duration of the jaundice. 

Poor health of the mother, and impoverishment of her blood during 
gestation, whether from chronic disease, as tuberculosis, or anti-hygienic 
conditions, also cause impoverishment and diminished coagulability of the 
blood of the child, and arc therefore causes of the haemorrhage. The ex- 
cessive use of diluent drinks or alkalies by the mother is believed by some 
to have a similar effect. 

In certain cases the haemorrhage is due to an inherited haeraorrhagic 
diathesis. In nine of Jenkins's cases the mothers were subject to monor- 
rhagia, and liable to bleed freely after parturition, and from injuries ; and 
seventeen other mothers had each lost more than one infant from umbili- 
cal haemorrhage. Probably in those cases in which the haemorrhage com- 
mences before detachment of the cord, and external to its point of inser- 
tion, the haemorrhagic diathesis is the main cause of the flow. 

Although the cause of umbilical haemorrhage in the majority of cases is 



SS UMBILICAL HEMORRHAGE. 

the vitiated state of the blood itself, observers, among others the late Sir 
James Y. Simpson, have met cases in which the haemorrhage was referable 
to the state of the vessels. In order that the vessels be effectually closed 
by the fibrinous coagula, their walls should have their normal contract- 
ility, but this is in great part lost by inflammation (arteritis or phlebitis) 
which sometimes occurs in these vessels, as we have already seen. Inflam- 
mation, whether of artery or vein, causes thickening and infiltration of 
its parietes, loss of tone on the part of the fibres of which they are com- 
posed, and therefore a patulous state of the vessel. Moreover, the in- 
flammation is apt to be suppurative, and the presence of pus in the vessel 
obviously hinders the formation of a firm and effective coagulum. 

Symptoms. — Ordinarily umbilical haemorrhage occurs without any pre- 
monition, but sometimes it is preceded by jaundice. Jenkins ascertained 
that jaundice was a prodromic symptom in 41 out of 178 cases, and be- 
sides the icteric hue, constipation, clay-colored stools, deeply tinged 
urine, etc., were sometimes recorded. Rarely colicky pains and vomiting 
preceded the haemorrhage. The blood may be arterial or venous, or both. 
It oozes slowly or rapidly, rarely escaping in a jet, even when there is 
reason to believe that it is arterial. 

Prognosis. — This is unfavorable. Statistics show that five in every 
six perish. The prognosis is most unfavorable when jaundice or jjurpura 
hsemorrhagica is present. Those are most likely to recover who have a 
healthy parentage, no obvious dyscrasia, and in whom the haemorrhage 
occurs late, and is not profuse. The average duration of the haemorrhage 
in 82 fatal cases in Jenkins's collection was three and a half days, the 
minimum being only three hours. After the arrest of the haemorrhage, 
death may occur from exhaustion or the dyscrasia. 

Treatment. — The treatment should be both constitutional and local. 
It is important, so far as time will permit, to treat the dyscrasia, and as 
the stools are apt to be constipated, a laxative is ordinarily indicated. A 
laxative is not only useful for its effect on the hepatic circulation, but as 
a derivative. Both Smith and Jenkins recommend calomel for this pur- 
pose. The modes of treating the bleeding parts have been various. 
Those most deserving of mention are the following : injecting a styptic 
into the open vessels, applying a styptic by compress or sponge to the 
navel, covering the navel with dry or wet plaster of Paris, constant pres- 
sure with the finger, which is tedious, but which maternal solicitude will- 
ingly provides, and lastly, the use of needles with ligature. All of these 
methods have been more or less successful in arresting the haemorrhage, 
but the last is most effectual, though painful. Two needles should be 
passed through the umbilicus at right angles, and a waxed thread wound 
around each in the form of the figure 8. In four or five days the needles 
should be removed, and a poultice or simple dressing applied. 



FEATURES, ETC., IN DISEASE. 89 



CHAPTER XIV. 

DIAGNOSIS OF INFANTILE DISEASES. 
General Observations. 

Diseases in early life differ in important particulars from those occur- 
ring in maturity. Some which arc common in the former age are un- 
known or are rare in the latter, and those which occur equally at all ages 
often present peculiar symptoms and a peculiar clinical history in the 
young. Therefore physicians who are skillful in treating adults, may be 
unskillful in treating children. Excellence as a physician of children can 
only by achieved by special and continued study of their ailments. 

Again, as regards the diseases of infancy, in which period there is a 
great amount of sickness and a large mortality, diagnosis must evidently 
be made from the objective symptoms ; from examining the features, 
attitude, utterances, the pulse, respiration, etc., and inspecting the 
surfaces, so far as they are accessible to view, and the eliminated pro- 
ducts. We lack for this age the important information which speech 
affords. Some general remarks, therefore, in reference to the appear- 
ances and functions of the system in early life, and the changes which 
they undergo in various pathological states, seem requisite, in order to a 
clearer appreciation of the symptoms, and more ready diagnosis of indi- 
vidual diseases. 

Features, External Appearance of Head, Trunk, and Limbs in Disease. 

In the new-born, as soon as respiration and the new circulation are 
established, the cutaneous capillaries become distended with blood, and 
the skin presents a congested appearance. By the close of the first week 
this external hyperamiia begins to abate, and is soon replaced by the 
normal capillary circulation. 

Icterus is common in the first and second weeks. Bouchut attributes it 
to mild hepatitis. A much more plausible view of its causation, and 
probably the correct one, is that of Frerichs, who attributes it to the 
effect on the hepatic circulation of ligation of the umbilical cord. By 
ligation the current of blood through the umbilical vein to the liver ceases, 
the amount of blood in the hepatic capillaries, which connect with the 
branches of the vein, diminishes, and then, according to Frerichs, by the 
law of diffusion, diversion occurs of a part of the bile from the hepatic cells 
into the capillaries, while the rest flows in the normal manner into the 



00 DIAGNOSIS OF INFANTILE DISEASES. 

bile-ducts. The degree of jaundice is proportionate to the amount of bile 
which enters the circulation. Icterus neonatorum is ordinarily not a 
disease of importance. If the general health remain good, it subsides 
without medicine in the course of one or two weeks, when the circulation 
through the liver becomes equalized and regular. 

The surface, or portions of the surface, of the new-born often present 
for a few hours a livid color, due to the mode of delivery. Protracted 
lividity occurs from atelectasis or malformation in the heart or great ves- 
sels ; lividity induced by exertion or excitement, while the respiration is 
normal, indicates malformation of the heart or vessels ; temporary lividity 
sometimes occurs in severe acute diseases, especially those of the respira- 
tory organs ; lividity, whether temporary or permanent, is a sign of 
imperfect dccarbonization of the blood. 

The cheeks of children are congested in febrile and inflammatory dis- 
eases, except in a cachectic or prostrated state of the system. Transient 
circumscribed congestion of the face, ears, or forehead constitutes a reli- 
able sign of cerebral disease. Strabismus occurring in connection with 
febrile reaction, oscillation of iris, inequality of pupils, and drooping of 
upper eye-lids, also denotes cerebral disease. The pupils are contracted 
during sleep ; evenly dilated in death. 

Dilatation of the alas nasi during inspiration, with contraction of the eye- 
brows and a countenance indicative of suffering, attends severe inflamma- 
tion of the respiratory organs. Absence of tears during the act of crying 
shows a severe and probably fatal form of disease in infants over the age 
of four months. 

Rapid wasting of the features, -causing deep suborbital depressions, 
prominence and pointedness of the cheek-bones and chin, and hollowness 
of the cheeks, is a sign of a severe diarrhceal malady ; the most striking- 
examples of this sudden collapse of features are afforded by patients 
affected with cholera infantum. In severe cases of this disease the physi- 
ognomy, from a state of fulness and health, presents in a few hours such 
a wasted and senile appearance that the friends with difficulty recognize 
the features with which they are familiar. Muscular tonicity is also 
greatly impaired in this disease, that of the orbicular muscles of the lips 
and eye-lids to such an extent that the mouth is open and eyeballs ex- 
posed during sleep. Great emaciation occurring gradually, is a symptom 
of subacute or chronic disease of a grave character, often of tuberculosis 
or chronic entero-colitis. 

Strabismus sometimes occurs in children who have no serious disease. 
It is then due to simple paralysis of one or more of the motor muscles of 
the eye. But when supervening upon other symptoms of a neuropathic 
character, it is a grave symptom, indicating organic disease of the en- 
cephalon, as effusion, meningitis, etc. A permanently downward direc- 
tion of the axes of the eyes, with small ncss of the face and great expan- 



ATTITUDE — MOVEMENTS — THE VOICE. 91 

sion of the cranium, is a sign of congenital hydrocephalus. The scalp in 
this disease is tense, bald, or sparingly covered with hair, the fontanelles 
and sutures open and enlarged, and the cranial bones yield to pressure. 
Great expansion of the cranium above the ears, while the frontal portion 
is not enlarged, or but slightly, denotes hypertrophy of the brain. 

The appearance of the general cutaneous surface possesses much greater 
diagnostic value in the diseases of infancy and childhood than in those of 
adult life. The eruptive fevers so common in the young, and compara- 
tively rare in the adult, reveal themselves to us in great part by the 
changes which they cause in the appearance of the integument. The 
peculiar color of the skin in constitutional syphilis, hereafter to be de- 
scribed, and which is more marked in infancy and early childhood than at 
any other age, is a diagnostic sign of great value in obscure cases. In the 
infant the cold stage of intermittent fever is manifested, not by muscular 
tremors, but by lividity, pallor, and the goose-skin appearance of the 
surface. 

Bulbous enlargement of the fingers and incurvation of the nails are 
signs of cyanosis, and therefore of malformation at the centre of the cir- 
culatorv apparatus, or of tuberculosis, or chronic pulmonary disease at- 
tended by malnutrition. Enlargement of the spongy portions of bones, 
causing prominences, softness, and bending of the bones, and consequent 
deformity of the limbs, patency of the fontanelles, a large and square 
shape of the head from calcareous deposit external to the cranium, and 
delaved dentition, are amon^ the sio;ns of rachitis. 

In early infancy the glands of the skin and mucous surfaces, or which 
connect by their orifices with these surfaces, are slightly developed. 
Therefore sensible perspiration and lachrymation are rare under the age of 
three months. A thick Meibomian secretion of a puriform appearance 
collecting between the eyelids is an unfavorable prognostic sign ; it indi- 
cates a state of great depression ; it is observed most frequently in cere- 
bral and intestinal maladies shortly before death. Passive congestion of 
the vessels of the conjunctiva sometimes occurs under the same circum- 
stances, due to feebleness of the heart's action, and imperfect capillary 
circulation. It indicates the near approach of death. 

Attitude — Movements — The Voice. 

A sharp, piercing cry, head firmly retracted, flexure of the limbs with 
a degree of rigidity, adduction of the great toe, clonic or tonic spasm of 
the muscles, irregular movements of one or more limbs, with conscious- 
ness impaired, or with mental hallucinations, are symptoms of grave dis- 
ease of the cerebro-spinal system. Irregular muscular movements partly 
controlled by the will, and occurring during full consciousness, are symp- 
toms of chorea, a disease nearly always ending favorably in children, 
though incurable in the adult. Contraction of the eyebrows, turning of 



92 DIAGNOSIS OF INFANTILE DISEASES. 

the eyes and face from light, avoidance of noises, as if painful, are signs 
of headache. Frequent carrying of the hand to the ear, and pressing 
with the ear against the breast of the mother or nurse, are symptoms of 
otalgia. Frequent carrying of the fingers to the mouth, in connection 
with fret-fulness or other symptoms of suffering, indicates stomatitis, 
gingivitis whether from difficult dentition or other causes, painful pharyn- 
gitis, or some obstructive disease of the larynx. Frequent rubbing or 
pressing the nose may be due to intestinal worms or intestinal irritation 
from other causes. It may be due to coryza or headache. Frequent 
forcible rubbing or striking the nose should lead to a careful examination 
and perhaps guarded prognosis. It often indicates grave cerebral disease, 
and may be a precursor of convulsions. 

In severe obstructive disease of the larynx the child is restless, moving 
from side to side. In most inflammations of the respiratory organs, a 
semi-erect position gives most relief. The voice in severe laryngitis is 
often hoarse or indistinct, and is usually so in the pseudo-membranous 
form ; in pleuritis or pneumonitis it is restrained and abrupt, since the 
movements of the walls of the chest give pain. 

The voice in severe diseases of the abdominal organs is feeble and 
plaintive. It is sometimes short and restrained in acute dyspepsia, in 
peritonitis, and in cases of great abdominal distension. The horizontal 
position gives most relief in abdominal diseases. In case of abdominal 
pain the patient often presses his hand upon the abdomen and flexes his 
thigh over it. Perfect quietude, with features sunken, and unchanged by 
smile or crying, is a symptom of severe and exhausting diarrhoeal affec- 
tions. 

Respiratory System. 

The respiration of the infant under the age of six months is very irregu- 
lar, and it is more irregular the nearer the time to birth. If the new- 
born infant be closely observed, it will be seen to sigh often ; it breathes 
pretty uniformly and regularly for a moment, and then, without appreci- 
able cause, the respiration is intermitted ; it holds its breath when it 
smiles or moves its head, or even its limbs ; it is very subject to hiccups ; 
this is more common the first week of life than at any other age. So 
much is the breathing of the young infant disturbed by these causes, that 
the number of respirations ordinarily varies in consecutive minutes. In 
order, therefore, to determine with accuracy the frequency of the normal 
respiration for this time of life, it is necessary to take the average of 
several observations. 

At birth, while the function of the heart has for months been regularly 
performed, the lungs are still quiescent. The one organ has been active 
during the greater part of foetal development, the other is yet untried. 
Hereafter, in the new order of things, so intimate is the relation between 



RESPIRATORY SYSTEM. 



93 



the heart and lungs, that the proper performance of the function of the 
one is essential to that of the other. Therefore the commencement of 
respiration and the return of circulation, which is modified and temporarily 
arrested at birth, are nearly simultaneous. Respiration commences in the 
first half -minute of independent existence ; often, indeed, attempts to in- 
spire occur before the delivery is completed. The exceptions to this early 
establishment of respiration are after tedious or unnatural births. The 
establishment of the new circulation is a moment later. 

Respiration ix Health. — As the air-cells at birth are closed, the 
establishment of respiration is difficult. The air at first penetrates a few 
pulmonary cells, but gradually more and more are inflated through the 
forcible inspirations which the crying of the infant produces, till after a 
variable time, respiration becomes easy and complete. If the cry be fee- 
ble, and especially if with this feebleness there be considerable congestion 
of the brain, the result of tedious birth, the full establishment of respira- 
tion is in a corresponding degree gradual and slow. 

The frequency of the respiration in health should be ascertained, in 
order to determine whether, in a given case, it be abnormally accelerated. 
The following table embodies the result of observations which I have 
made, in order to determine the normal frequency of respiration in the 
first year of life. 

Normal Infantile Itesjnration (number per minute). 















Age. 
















From first From close 

half hour to of first week 

close of first to close of 

week. first month. 


From close 

of first 

month to 

closeof third 


Close of 

third to close 

of sixth 

month. 


Close of 

sixth month 

to close of 

first year. 




First 
half 
hour. 














6 

"5 
> 

< 


Asleep. 


Awake. 


< 


6 fS, 
< < 


"5 
< 




6 
a 

< 


ST 
< 


Number of observations 


29 


28 


14 


13 


13 16 j 10 


* 




19 


6 


Extreme number of res- 
pirations per miuute.. 


25-104 


32-64 


40-64 


40-96 


28-60 


32-68 28-52 


36-88 


24-40 


28-64 


24-30 


Mean number of respi- 
rations per minute 


4S.5 


, 


52 


59 


45 


51 


39 


u 


33 


41 


29 



As the child advances from the age of one year, the number of respira- 
tions per minute gradually diminishes ; but through the whole period of 
childhood it remains greater than in the adult. At the age of five years, 
when the child is quiet, but awake, it is about I 
years, about 22. 



at the age of ten 



O-t DIAGNOSIS OF INFANTILE DISEASES. 

Kespiration ik Disease. — Tn cerebral diseases the respiration is apt to 
be slow, and if somnolence occur, intermittent, and accompanied by sigh- 
ing. In young infants, in the drowsiness which supervenes when the 
blood is imperfectly decarbonized, during severe attacks of capillary bron- 
chitis, or broncho-pneumonia, respiration is apt to be intermittent. 

In inflammatory diseases of the larynx and trachea, respiration is but 
slightly accelerated, and, if there be no obstruction, its rhythm is normal ; 
if there be obstructive disease, its rhythm is altered ; the inspiratory act 
is lengthened. In bronchitis, respiration is accelerated in proportion to 
the degree of extension downward of the inflammation. It is in no dis- 
ease more accelerated than in severe capillary bronchitis. 

In pleuritis and pneumonitis, the respiration is accelerated in propor- 
tion to the extent and acuteness of the inflammation. Inspiration ending 
abruptly, and succeeded by an expiratory moan, is a symptom of both 
pleuritis and pneumonitis in their acute stages. In certain cases of irrita- 
tive or inflammatory disease of the abdominal organs, respiration presents 
a similar character ; it is modified in this manner in consequence of the 
pain experienced in movements of the diaphragm. Ordinarily, however, 
in abdominal diseases, respiration is nearly natural. 

The cough is an important diagnostic symptom. It is loud and sonor- 
ous in spasmodic croup, hoarse or harsh in true croup, clear and distinct 
in bronchitis, suppressed and painful in the early stages of pneumonitis 
and pleuritis, convulsive and with more inspirations than expirations in 
pertussis. A cough due to coexisting bronchitis is one of the first and 
most constant symptoms of measles. Typhoid and remittent fevers, 
difficult dentition, intestinal worms, irritating ingesta, and severe burns, 
sometimes give rise to a cough, which is nearly dry and painless. Occur- 
ring in such diseases, it is sometimes dependent on more or less bronchitis, 
to which the primary disease has given rise. 

Circulatory System. 

In all ages and countries the pulse has been considered an important 
symptom, both in diagnosis and prognosis. It aids the practitioner in 
determining, approximately, not only the character but the gravity of 
diseases. It is somewhat remarkable, from the importance which is 
attached to the pulse in medical practice, that its natural frequency and 
its character in infancy are not more accurately known. It is true that 
eminent observers, as Trousseau and Yalleix, have published statistics 
relating to the infantile pulse in health, but these statistics disagree, and 
therefore do not afford a reliable standard with which to compare the 
pulse in disease. Moreover, some published statistics of the pulse possess 
but little value, from the small number of observations ; some from the 
fact that records of the infantile pulse are grouped with those of older 



CIRCULATOKY SYSTEM. 



95 



children ; and others because the state of the infant, as regards its activity 
or emotions, is not mentioned. 



Pulse in Health. — It is not easy to collect statistics of the healthy 
pulse for the period of infancy, which are entirely free from error, since 
there arc often slight derangements of the system in the infant, which are 
not manifested by any marked symptoms, but which produce accelera- 
tion of pulse. In collecting the following statistics, it was my endeavor 
to avoid sources of error so far as possible. 

In ordinary cases the movements of the heart begin about one-eighth 
of a minute after birth. They are at first slow, the ventricular contrac- 
tions not numbering more than eight or ten by the close of the first 
quarter minute. In the second quarter the cries are vigorous, and the 
pulse now is rapidly accelerated, rising commonly above 120, and some- 
times above 160 beats per minute. In fifty-seven observations of the 
pulse in healthy infants during the first half hour of life, after the first 
quarter of a minute, I found that the extremes, with one exception, were 
104 and 1G4 — average, 139. 

Tahle of Infantile Pulse in Health. 





Age. 








From close of 


From close of 


From close of 


From close of 








first week to 


first month to 


third month to 


sixth month to 




First weetc. 


close of first 


close of 


close of 


close of first 








month. 


third. 


sixth. 


year. 




Awake. 




Awake. 




Awake. 




Awake. 




Awake. 






Quiet ; 


^ 


Quiet ; 


,-; 


Quiet ; 


^ 


Quiet ; 




Quiet; 


£ 




moving 


o 


moving 


o 


moving 


o 


moving 




moving 


<L> 




slightly ; 




slightly ; 




slightly ; 




slightly ; 




slightly ; 






nursing. 


A 


nursing. 


< 


nursing. 


< 


nursing. 


" 


nursing. 


< 


No. of ob- 






















servations. 


22 


1G 


10 


10 


15 


1~ 


25 


G 


20 


3 


Extremes . . 


104-152 


10S-140 


124-IG0 


104-144 


112-148 


104-132 


112-146 


104-1 1G 


112-144 




Mean 


12G 


122 


139 


US 


132 


US 


129 


108 


127 


109 



" M. Lcdeberder, " says Bouchut, " could only count the pulse in the 
first minute of life in six children, and he lias observed from 72 to 94 
pulsations." Yallcix estimates the pulse, between the ages of two and 
twenty-one days, at 87. Trousseau states that the pulse, in the first week 
of life, varies from 78 to 150 ; and Dr. Gorham's observations are some- 
what similar to Trousseau's. My observations, as seen from the above 
table, do not correspond with the assertions of Ledeberder and Yalleix. 
Indeed, if there were no conflicting testimony, there would still be a 
strong presumption that these authors are in error, for we would not sup- 



96 



DIAGNOSIS OF INFANTILE DISEASES 



pose that the pulse of the infant, in whom there is greater functional 
activity, both muscular and visceral, would fall so much below that of the 
foetus. It is probable from the expression " could only count the pulse 
... in six children," that Lcdeberder and perhaps Yalleix counted the 
pulse at the wrist, which, with exceptional cases, is very difficult and often 
impossible in the first week of life, and that they missed some of the 
beats, or, not unlikely, sometimes counted their own pulse. Immediately 
after birth there is so little force of the ventricular systole, and the 
extreme arteries, therefore, of the system pulsate so feebly, that neither 
in the limbs nor at the anterior fontanelle can the frequency of the pulse 
be readily ascertained. It can be readily and accurately ascertained only 
by auscultation, or by placing the hand on the precordial region, or 
directly after birth by the pulsations in the umbilical cord. 

The average pulse of the healthy infant in the first and second months 
is, according to Trousseau, 137 per minute, 128 from the third to the 
sixth month, and 120 from the sixth to the twelfth month. It is seen 
that his observations agree closely with mine, as 'regards infants who are 
quiet but awake. One point of interest, established by the above statis- 
tics, is the great diminution in the frequency of the pulse in sleep. 

Pulse during or after Active Movements or Great Mental Excitement. 



Age. 







Close of first 


Close of first 


Close of third 


Close of sixth 




First week. 


week to close of 


to close of third 


to close of sixth 


month to close 






first month. 


month. 


month. 


of first year. 




140 


162 


176 


132 


132 




160 


156 


152 


148 


144 




140 


140 


158 


148 


152 




152 


152 


144 


144 


182 








152 


156 


198 






.... 


180 


156 


160 


Extremes . . . 


140-160 


146-162 


144-180 


132-156 


132-198 


Mean 


148 


152 


160 


147 


156 



It is seen, by the above table, that by active exercise or great mental 
excitement the pulse may become as rapid as in grave diseases. There is 
greater acceleration of pulse from the emotions and from exercise in feeble 
than in robust children. Obviously, in order to determine to what extent 
the pulse is accelerated in disease, it is necessary that it should be counted 
during a state of quietude. As the age increases, it is less and less influ- 
enced by the emotions and physical exertion ; still, during the whole 



ANIMAL HEAT. V i 

period of childhood, such influences do have more or less effect on its 
frequency. 

Pulse in Disease. — Febrile and inflammatory diseases produce greater 
acceleration of pulse in early life than in maturity. Diseases, or derange- 
ments of system, particularly those of the digestive organs, which do not 
materially affect the pulse in the adult, often cause acceleration of it in 
children. The febrile pulse of early life usually has exacerbations in its 
frequency. These commonly occur in the latter part of the day. Dis- 
tinct and more or less regular febrile exacerbations and remissions are 
common in several diseases of early life, some of which are serious, while 
others involve little danger. Among these diseases may be mentioned 
difficult dentition, intestinal worms, incipient meningitis, and constipa- 
tion. An intermittent and irregular pulse is common in fully developed 
meningitis and certain other severe organic diseases of the encephalon. It 
may be due also to disease of the heart, and it also occurs in some chil- 
dren from temporary disturbance of the digestive function. The pulse is 
slow in compression of the brain, and also in sclerema of the new-born. 

Animal Heat. 

The internal temperature of the body in a state of health is uniform. 
In 33 infants under the age of seven days, M. Roger found the average 
temperature 9S.G Fahr., while in 25, from four months to fourteen years 
old, it was 99°. The external temperature alone varies in a state of 
health, according to the temperature of the atmosphere. 

Elevation of temperature above the normal standard is a sign of inflam- 
matory and febrile affections. The increase of heat varies according to 
the character of the disease and its type. In favorable cases of inflam- 
mation and in simple fevers it is not ordinarily more than two or three 
degrees. The greater the severity and malignancy of inflammatory and 
febrile diseases, the greater the elevation. An elevation of more than six 
degrees indicates a form of disease which is likely to prove fatal. It is 
rare that the temperature, even in fatal cases, rises above 107°. In 
measles the temperature in the eruptive stage is from 101° to 103° ; in 
scarlatina from 102° to 104°, if no complication exist. In diphtheria the 
temperature is elevated at first, but it is apt to fall to nearly the normal 
during the stage of profound toxaemia. 

Reduction of the internal temperature is an unfavorable prognostic 
sign ; it is observed, a few hours before death, in infants who are greatly 
reduced by certain chronic diseases, as entero-colitis. In these cases the 
tongue and even sometimes the breath communicate to the finger or hand 
a sensation of coldness. 

The importance of thermometric observations, as an aid to the diagnosis 
of children's diseases, is within a few years more fully recognized by the 



9S DIAGNOSIS OF INFANTILE DISEASES. 

profession. Two diseases which, in their commencement, present very 
similar symptoms, often vary as regards the temperature. Thus, men- 
ingitis, presenting in its first stages symptoms very similar to those of 
typhoid fever, has a lower temperature till an advanced period, when the 
amount of heat increases. 

Digestive System. 

Inspection of the buccal and faucial surfaces discloses some of the 
most frequent local diseases of infancy, as the various forms of stomatitis, 
and others which, though not frequent, involve great danger, as gangrene 
of the mouth, diphtheria, and retro-pharyngeal abscess. Inspection of 
the tongue aids in determining in many cases whether the disease be pur- 
suing a favorable course, or has become asthenic, and is exhausting the 
vital powers. 

Febrile movements, even when slight, give rise to coating of the 
tongue, and intumescence and distinctness of its follicles. The eruptive 
fevers are attended by changes upon the buccal and faucial surfaces which 
possess diagnostic and prognostic value. Hyperemia of these surfaces 
appears early in rubeola and scarlatina, prior to those phenomena which 
are justly regarded as pathognomonic. It is, therefore, often an important 
sign in the initial period of these diseases when the diagnosis is obscure. 
The appearance of the fauces in diphtheria and croup, indicating not only 
the nature of the disease, but its gravity, need only be referred to in this 
connection. 

Inspection of the buccal and faucial surfaces sometimes enables us to 
form a probable opinion in reference to the nature of diseases which are 
seated in other parts. In the infant protracted stomatitis is a common 
accompaniment of chronic diarrhoea, and it indicates its inflammatory 
nature. 

Vomiting is more frequent in infancy than in childhood, and in either 
period than in adult life. It is common in cerebral affections, and is one 
of the first symptoms of scarlet fever, and is not uncommon, though less 
frequent, in the commencement of the other essential fevers and of acute 
inflammations. It is a symptom of indigestion, entero-colitis, cholera 
infantum, and intussusception ; it is common, also, after the paroxysmal 
cough of pertussis, and not infrequent in the bronchial inflammations of 
young infants. In both these diseases it is excited by the muco-purulent 
matter upon the faucial surface. 

Intestinal gas is in part secreted or exhaled from the mucous membrane, 
as the experiments of Hunter and others have shown, and is in part the 
product of chemical changes in the food. A certain amount of gas in 
the intestines is normal ; it subserves a useful purpose. An abnormal 
amount of it is common in various diseases, as indigestion, chronic entero- 
colitis, peritonitis, typhoid fever. It is a frequent cause of gastralgia and 



DIGESTIVE SYSTEM. 



99 



Fig. 4. 




enteralgia in the infant. In scrofulous or feeble infants, with impaired 
muscular tonicity and faulty digestion, the abdomen is often habitually 
more or less distended with gas, which does 
not, under such circumstances, give rise to 
pain or other local symptoms ; it has signifi- 
cance as showing the general condition of the 
child. 

In the rachitic, whose thorax is compressed 
and liver often enlarged, while the vertebral 
column is shortened, the abdomen is com- 
monly protuberant. In feeble children, not 
decidedly rachitic, whose lungs are seldom 
fully inflated, and whose chests are conse- 
quently depressed, the abdomen is also promi- 
nent. The accompanying wood-cut repre- 
sents one of these cases, presented for treat- 
ment at the outdoor department at Bellevue. 

In feeble children who have suffered from 
repeated and protracted attacks of bronchitis, 
and whose chest- walls are consequently de- 
pressed, a similar abdominal prominence oc- 
curs. 

Retraction of the abdominal walls is common in meningitis, and in 
many exhausting diseases. Tenesmus is a symptom of intussusception in 
the infant, and of colitis in children. 

Much light is thrown on the character of intestinal diseases by the ap- 
pearance of the stools. Muco-sanguineous stools accompanied by fever, 
arc a sign of colitis. Stools containing unmixed blood, and not accom- 
panied by fever, may result from a rectal polypus, and from purpura 
hamiorrhagica. Scanty evacuations of blood, with obstinate constipa- 
tion, are a symptom of intussusception in infants. 

The alvine discharges of infants often present a green color ; some- 
times they have the normal } T ellow hue when passed from the bowels, but 
become green on exposure to the air, or from reaction of the urine. By 
the microscope the green coloring matter is seen to occur in small, irregu- 
lar masses. This green substance has been supposed to be bile. I am 
convinced that, as it occurs in the stools of the infant, it is commonly 
produced by the action of the intestinal secretions on the contents of the 
intestines ; perhaps the action is upon the bile, which is mingled with 
the contents ; for I have often noticed that the contents in and above the 
jejunum were yellow, while in and below the ileum their color was green. 

The green hue may occur from very different causes. It may be due 
to over-feeding, to the action of cold, to irritating ingesta, to inflamma- 
tion, etc. ; it may be transient, subsiding within a day or two, or it may 



100 DIAGNOSIS OF INFANTILE DISEASES. 

continue several days. All infants, at times, have green evacuations, 
even when they appear in good health. 

In a large proportion of the cases of diarrhoeal maladies occurring during 
infancy the stools give an acid reaction with litmus-paper. This acid, if 
in considerable quantity, is irritating, increasing the peristaltic movements 
of the intestines, and the functional activity of the intestinal follicles, caus- 
ing erythema of the skin around the anus, and reacting upon and intensify- 
ing the intestinal disease. Hence the indication for the use of antacids in 
the diarrhoeal affections of infancy. 

The presence of intestinal worms and the species may be ascertained by 
microscopic examination of the stools of the child who is affected with 
these entozoa. The stools contain ova, which differ in size and shape ac- 
cording to the species of worm. 

Nervous System. 

Pain. — This symptom affords important aid to the physician in deter- 
mining the seat and nature of the diseases of children. Pain in the head 
may occur in them from coryza involving the frontal sinuses, or from 
febrile movement in the commencement of an essential fever, or of inflam- 
mation of one of the organs of the trunk. Produced by such a cause, it 
abates in two or three days. If it be protracted, whether constant or in- 
termittent, it is in many cases not neuralgic, as it so often is in the adult, 
but is due to organic disease of the brain or meninges. Complaint, there- 
fore, of headache in a child, without any apparent general cause or local 
cause external to the cranium, should awaken solicitude, and, if it be pro- 
tracted, the physician should examine carefully in reference to the pres- 
ence of a cerebral or meningeal disease. Mild frontal headache, continu- 
ing for weeks or months, sometimes occurs in children suffering from so- 
called spinal irritation. In these cases pressure over the first cervical 
vertebra and the occiput is apt to increase the pain. 

Grave thoracic or abdominal inflammations in the adult are almost always 
attended by a corresponding amount of pain and tenderness ; but in chil- 
dren these symptoms are often absent, or, when present, are often not com- 
mensurate with the amount of disease. Thus, entero-colitis of nursing in- 
fants is, in a large proportion of instances, almost free from these symp- 
toms, and the same may be said of many cases of pneumonitis in young- 
children ; namely, those cases produced by extension of inflammation from 
the bronchial tubes and from hypostasis. 

Pain in the chest or abdomen, occasional or constant, continuing for 
weeks or months, with fever, and unattended by thoracic or abdominal 
disease, indicates caries of the vertebra?. Its most common seat is the 
epigastric, umbilical, or hypochondriac region. It is a neuralgia due to 
irritation of the sensitive root of one or more of the spinal nerves. It is 
a very important symptom to the diagnostician, showing the nature of the 



THERAPEUTICS. 101 

disease, which in its incipiency is so obscure. Pain in the leg, especially 
the inside of the knee, is of a similar character, indicating disease of the 
hip-joint. 

Children with certain acute febrile and inflammatory diseases sometimes 
have hyperesthesia of portions of the surface ; it is especially marked 
upon the anterior aspect of the trunk. The physician might be misled 
into the belief that the tenderness occurred oyer the seat of the disease 
and indicated an inflammation ; but the pain of hyperesthesia can be 
diagnosticated from that of inflammation by the fact that it is so exten- 
sive, is less on firm than light pressure, and is especially observed upon 
the inner surface of the thighs. The symptoms pertaining to the nervous 
system occurring in the various diseases treated of in this book will be 
fully described in connection with those diseases, and, therefore, need 
not detain us in this connection. 



CIIAPTEE XV. 

THERAPEUTICS. 

The young practitioner is often perplexed in deciding exactly what dose 
of the stronger and more dangerous medicinal agents to prescribe for a 
child. A practical rule, which holds good for many medicines, has been 
proposed by Dr. Cowling, as follows : " The proportional dose for any 
age under adult life is represented by the number of the following birth- 
day divided by twenty-four." This rule is inadmissible for infants under 
the age of six months, but will apply for those that are older, for the use 
of a large number of medicines. Another rule proposed by another 
British physician, Professor Clarke, is based on differences in weight of 
children and adults : The adult dose is represented by 150. The dose 
of a child is determined by dividing its weight in pounds by 150. But 
it is an interesting fact, and one of practical importance, that children 
bear and often require, in order to obtain the desired effect, a much 
larger proportionate dose of certain agents than adults. This is partly 
attributable to the active elimination in childhood. Belladonna is nota- 
bly one of the agents which childhood tolerates ; and it may be added 
that some children can take a much larger dose of it than others, without 
producing the physiological effects. Thus, recently, I increased gradu- 
ally a reliable preparation of the tincture to twelve drops for a child of 
four years, without producing the usual efflorescence ; and Farquharson 
says " the dose ... I have pushed in a child of ten, suffering 
from incontinence of urine, to fjij (British Pharmacop.) with good 
effect, and the development of mild forms of physiological disturbance." 



102 THERAPEUTICS. 

Arsenic is also Letter tolerated by children than adults. An infant of six 
months can take two-drop doses of Fowler's solution three times daily 
without ill effect. Prussic acid, strychnia, iron, ipecacuanha, and alcohol 
arc also required in larger proportionate doses in childhood than is indi- 
cated by the rule either of Dr. Cowling or Professor Clarke. 

When practicable, medicines should be given in the liquid form. 
Those not soluble may often be given in suspension, in some vehicle which 
in great part disguises the taste. The best vehicle for the bitter vegeta- 
bles, as the salts of quinia, with which I am acquainted, is the elixir 
adjuvans of Caswell and Hazard. The following is the formula for its 
preparation : — 

]J. Cort. aurant., | ij. 

Pulv. seruin. coriandr. 

Pulv. semin. carui, aa 5 j. 

Pulv. cort. pruni Virginianse, | iv. 

Pulv. rad. glycyrrhizse, 3 vj. Misce. 
Menstruum, Alcohol, partis j. 

Aquse, part. ijss. Misce. 
Percolat. 0. v, et adde — 

Syr. simplic, 

Aquae, a a Oijss. 

The elixir adjuvans may also be advantageously employed in the ad- 
ministration of many other medicines apart from those which are repul- 
sive on account of their bitterness. It holds them in suspension so that 
if they have a greater specific gravity than the elixir it is necessary to 
shake the bottle thoroughly before using it. The elixir taraxaci comp. 
is another good vehicle for bitter vegetables, although, like the elixir 
adjuvans, not officinal. I am sure from many observations, that unpleas- 
ant doses are apt to be wasted to a greater or less extent, and the repug- 
nance of children to medicines employed has induced many a parent to 
seek other and less disagreeable modes of treatment. Chemistry has 
greatly aided the therapeutics of childhood, in that it has enabled us, in 
so many instances, to prescribe the active principles in place of the large, 
nauseous doses formerly employed. 



PART II. 

CONSTITUTIONAL DISEASES. 



Fig 



SECTION I. 

DIATHETIC DISEASES. 

CHAPTER I. 

EACHITIS. 

Rachitis, or rickets, consists in faulty and abnormal nutrition and 
perverted and impaired function of the tissues from which hone is de- 
veloped, namely the periosteum and epiphyseal cartilage. 

Age. — This disease commences in most instances between the ages of 
six months and two years. Now and then we meet cases of its earlier as 
well as later commencement, and skeletons arc preserved 
in museums, which seem to show that in rare instances 
rachitis is congenital. Yirchow alludes to such a speci- 
men in the AYurzburg Museum, and Hitter von Ritter- 
shain describes another in the museum of the Franz 
Joseph Hospital in Prague. In the Wood Museum of 
Bellevuc Hospital is a similar skeleton presented by 
myself, and represented in the accompanying wood-cut. 
The infant in this case died a few hours after birth, 
of atelectasis, apparently produced by the contracted 
state of the thoracic walls. The parents are hard-work- 
ing English people, whose surroundings are such as are 
known to predispose to rachitis. 

The skeleton, as is seen in the representation, shows 
the rachitic deformities in a marked degree. The dis- 
section was made by Prof. Francis Delafield. There 
was no suspicion of syphilitic taint in this case. Prof. 
A. Jacobi described a case of congenital rachitis, in 
which craniotabes had occurred, in an interesting mono- 
graph published in the New York Obstetric Journal, in 
1870, and another very remarkable case of congenital rachitic craniotabes 
is related by Dr. Heitzman of New York. In Heitzman's case a woman 




104 RACHITIS. 

during pregnancy had for months frequently inhaled each day the fumes 
of lactic acid, an agent which we will see produces rachitis if intro- 
duced in quantity into the system when the bones are immature and 
in a state of development, and the infant, horn at term, died imme- 
diately. " It exhibited the signs of congenital rachitis in a high 
degree. The skull bones were completely absent. In the cartilages of 
the bones of the extremities and of the ribs, there were scanty depositions 
of lime salts, and numerous infractions. The death of the child was evi- 
dently due to the absence of the skull bones, inasmuch as the pressure of 
the womb during delivery caused cerebral hemorrhage. All the organs of 
the chest and abdomen were found in full development and healthy" 
(Communicated by Dr. Heitzman to the author). Whether or not we 
accept as genuine all the reported cases of foetal rachitis, there can be lit- 
tle doubt, from the number of observations already made and carefully 
recorded, and from the affirmative opinion of high authorities like Yir- 
chow, that rachitis does occur during intra-uterine development. But 
with few exceptions this disease begins in the first months of infancy. 
Enlargement of the costo-chondral articulations, known as the " rachitic 
rosary," which is one of the earliest and most reliable signs of rachitis, 
has been observed, though rarely, in infants of two or three months. It 
should not, however, be regarded as a sign of rachitis unless the enlarge- 
ment be so great that it can be readily appreciated by examination through 
the integument or by sight ; for in young children, with the bones in the 
process of normal development, these joints always have a greater diame- 
ter than that of the ribs. After the age of two years the number of 
those affected with rachitis gradually becomes less as we pass toward man- 
hood. 

Published statistics relating to the commencement of rachitis are mostly 
derived from European hospitals. The following are the aggregate 
statistics of Brunnicke, Yon Rittershain and Ritchie, giving the age at 
which this disease began or was first observed : 

During the first half year, 99 

During the second half of first year, ..... 259 

From the first to second year, 342 

" second to third " 134 

" third to fourth " 31 

" fourth to fifth " 17 

" fifth to ninth " 21 

Total, 903 

Is rachitis ever developed in the adult ? Osteo-malacia, or mollities 
ossium, a rare disease of adults, occurring with few exceptions in Avomen 
after childbirth, though adult males are occasionally affected, resembles 
rachitis, since it is attended with softening of the bones from the absorp- 



RACHITIS. 105 

tion of their calcareous element. Trousseau, and following him, Bou- 
chut, believe in their essential identity, regarding their differences as due 
to the difference in age, and especially to the fact that in osteo-malacia 
the bone has attained its growth, whereas in rachitis it is still growing. 
Moreover, as arguments in favor of their close relationship, rachitis and 
osteo-malacia are found to require very similar treatment, and women 
after childbirth resemble children as regards aptitude for disease. 

The two diseases evidently have a kinship, though pathologists have 
hesitated to regard them as identical ; rachitis consisting, as we have 
seen, in a disturbed nutrition of the osteo-plastic tissue, so that little or 
no lime is deposited in the newly-formed layers of bone, while in molli- 
ties, the lime salts are absorbed from the adult and fully formed bone. 
Dr. Heitzman, who before his arrival in this country had established a 
reputation as a leading authority in regard to the etiology of rachitis, be- 
lieves in the essential identity of these two diseases, as will be seen from 
his interesting letter on a following page. His experiments certainly 
afford strong evidence of their identity. 

Causes. — Rachitis, as we have stated elsewhere, is entirely distinct in 
its nature from scrofula. The scrofulous are not likely to become 
rachitic, nor the rachitic scrofulous. Proneness to low grades of inflam- 
mation or to hyperplasia of the lymphatic glands which characterizes 
scrofula, seldom exists in connection with swelling of the bones or other 
manifestations of rachitis. The differences between the scrofulous and 
rachitic diatheses, which indeed seem to exclude each other, are marked. 
The scrofulous are well developed and of good height, as a rule, while the 
rachitic are stunted. Scrofula manifests itself not less frequently in child- 
hood than in infancy, whereas rachitis we have seen is especially a disease 
of infancy. Again, as showing the difference between the two, scrofula 
is not infrequently associated with tuberculosis, whereas rachitis with 
tuberculosis is rare. 

Residence in a cold and moist climate, or in dark, damp, and ill-ven- 
tilated apartments, is a cause of rachitis. Therefore it is more common 
in the north of Europe than in the warm and equable climate of southern 
Europe ; in the damp and dark basements and alleys of the city, than in 
dry and airy country residences. In deep valleys, shut out from the 
solar rays, rachitis is more common than among people of the same habits 
and social position living in elevated and sunlit localities. 

In some infants there is an undoubted hereditary predisposition to 
rachitis, due to disease or feebleness of one or both parents. The off- 
spring of a tubercular or syphilitic, or otherwise enfeebled parent are more 
apt to become rachitic than those of healthy ancestry, and it appears 
that disease of the mother is more apt to entail a rachitic predisposition 
than that of the father. The mother presented traces of rachitis in 27 
out of 71 cases observed by Ritter von Rittershain. Among the parental 



106 RACHITIS. 

causes are advanced age of the father, poverty, hardships, and defective 
nutrition of either parent, and exhausting discharges of the mother, as 
purulent, hsemorrhoidal, and uterine fluxes. Mothers in habitual ill- 
health, over-worked, and poorly nourished, though without actual dis- 
ease, like many in the tenement houses of the cities, are liable to have 
rachitic children. 

The most common cause, however, is the use of food not sufficiently 
nutritious, or if nutritious, such as is not adapted to the feeble digestive 
powers of the infant, as breast-milk, thin and deficient in nutritive 
properties, or artificial food which is not adapted to the age of the in- 
fant. Rachitis is not, therefore, caused by the use of any particular kind 
of food exclusively, or any particular ingredient in the food, but by the 
use of the most diverse alimentary substances, provided that they are not 
adapted to the stage of development and the condition of the digestive 
organs. Those prematurely weaned, and given a food which is not a 
proper substitute for breast-milk, those too long wet-nursed and not 
allowed the additional nutriment which they require, and those, too, 
whose digestion is feeble naturally, or through disease, are especially lia- 
ble to become rachitic. We meet rachitis often in city and especially 
tenement house practice, as a sequel of exhausting diseases, such as the 
eruptive fevers, pertussis, and particularly protracted intestinal catarrh. 

It might be supposed from the nature of this malady that the use of 
food deficient in lime and phosphoric acid is the common cause, but facts 
show that this is not the correct view of its etiology, as it ordinarily 
occurs, although in the treatment, phosphate of lime is undoubtedly use- 
ful. The altered and abnormal nutrition of the osteo-plastic tissue is the 
immediate cause ; and this occurs in those whose food contains a suffi- 
cient amount of lime and phosphoric acid, as well as when these substances 
are insufficient. 

The very interesting fact has been brought to light by experiments that 
small repeated doses of phosphorus produce rachitis in certain lower 
animals by disturbing the nutritive process of the osteo-plastic tissue, and 
the theory now accepted by many who have given special attention to 
the subject is, that some substance introduced into the system in the 
ingesta, or, more frequently, produced in the digestive process, irritates 
like phosphorus the bone-producing tissues, so changing their function 
that true bone is no longer produced, while it probably acts as a solvent 
to the lime contained in the nutritive fluid ; so that instead of being de- 
posited upon the surface of the bone, it remains in a liquid state and is 
eliminated from the system. Dr. Heitzman, formerly of Vienna, but 
now of New York, has done much to establish this theory. He has 
produced what seems to be true rachitis in animals by feeding them 
with lactic acid, and the inference is that it is an acid or acids, either the 
lactic, or the lactic with allied acids, which produce rachitis as it ordi- 



RACHITIS. 107 

narily occurs in children. We know that in various states of indigestion and 
defective assimilation acids are produced in abundance during the period 
of infancy, and what more natural, in view of the facts, than that they are 
the active agents in producing the rachitic state. The irritative agent must, 
in order to reach the bones and cause the phenomena of rachitis, pass 
through the blood. But physiologists tell us " Among the organic acids 
the existence of lactic acid in healthy blood is not yet entirely beyond 
doubt, but it has been found in the latter under abnormal conditions" 
(Heinrich Frey, of Zurich). 

The following letter from Dr. Heitzman, bearing upon this subject, will 
be read with interest : 

New York, May 30, 1881. 

Dear Doctor : — In reply to your favor, I send you an account of my experi- 
ments relating to racliitis and osteo-malacia, first published in the Vienna 
Academy of Sciences, June, 1873. 

Marchand, Ragsky, Lehman, Simon, and others have found free lactic acid in 
the urine of persons suffering from racliitis and osteo-malacia. C. Schmidt dis- 
covered lactic acid in the liquid of malacic shaft-bones which were transformed 
into globular cysts. Encouraged by these chemical researches, I undertook an 
experimental series on the action of lactic acid, administered both by mouth and 
subcutaneous injection, upon the bones of living animals, which experiments 
were started in April, 1872, and continued until the end of October, 1873. The 
experiments were made upon five dogs, seven cats, two rabbits, and one squirrel. 
On dogs and cats under one year of age, the lactic acid, given either by mouth or 
injection, in combination with the restricted administration of calcareous food, 
produced swelling of the epiphyses of the shaft-bones and the anterior extrem- 
ities of the ribs. This result was plain in the second week after the beginning 
of the lactic acid treatment. Up to the fourth and fifth weeks the swelling of 
the epiphyses and the ends of the ribs kept increasing, and they were accom- 
panied by curvatures of the bones of the extremities. As accompanying symp- 
toms I noticed catarrhal inflammation of the conjunctiva, the mucosa of the 
bronchi, the stomach, and the intestines, emaciation and convulsive movements 
of the extremities. The microscopic examination of the epiphyses gave an 
image fully identical with that of the epiphyses of ricketty children. Upon 
continuing the administration of the lactic acid, the swelling of the epiphyses 
of the shaft-bones gradually increased, and so did the curvatures of the shaft- 
bones. After four or five months of lactic acid treatment, under often repeated 
catarrhal inflammations of the above-named mucous layers, the shaft-bones be- 
came soft to such a degree that they could be bent like branches of a willow- 
tree. After four to eleven months of the lactic acid treatment, the microscopic 
examination of the bones gave a result corresponding to that of bones of women 
who had died of osteo-malacia. In the three herbivorous animals no swelling 
of the epiphyses was noticeable. One rabbit died three months, the other five 
months after the commencement of the administration of the lactic acid, both 
with the symptoms of inanition. No marked symptoms of rachitis and malacia 
were traceable in the bones of these animals. The squirrel, on the contrary, 
which died after thirteen months of treatment with lactic acid, gave all the feat- 
ures characteristic of osteo-malacia. 

My experiments gave the result tliat by continuous administration of lactic acid 



108 RACHITIS. 

at first rickets, afterward osteo-malacia, could artificially be produced upon flesh- 
eaters, while on herbivorous animals osteo-malacia sets in icithout preceding symp- 
toms of rickets. 

Through these experiments I have proved the identity of rachitis and osteo- 
malacia. The differences observed in them are attributable to differences in 
the age and in the state of the bones, when the solution of the lime salts is es- 
tablished. Yours truly, 

D. S. H. 

That other experimenters have failed to produce rachitis, Dr. Heitz- 
man attributes to the fact that the animals on which they experimented 
were too old. 

Experimental investigations in regard to the causation of rachitis have 
therefore revealed the interesting fact that certain chemical agents intro- 
duced into the system produce rachitis, and from what is known of the 
nature of this disease and the conditions under which it is developed, it 
appears probable that the presence of lactic acid in the blood is the cause 
in certain cases, while there are other cases which we must attribute to 
other agencies besides the lactic acid. There are many parallel instances. 
Cirrhosis, for example, is often caused by alcohol, but no one attributes all 
cases of this malady to it. 

In the New York Infant Asylum, a few years since, one in every nine, 
by actual count, presented marked rachitic symptoms. Some who had 
the disease were suffering or had recently suffered from indigestion and 
gastro-intestinal derangements, such as are known to generate acids ; but 
others were wet-nursed, and gave no evidence of faulty digestion and 
nutrition. By a more liberal diet, by adding to the dietary, among other 
articles, the juice of meat, the disease became much less frequent, and 
now it is seldom that a case with marked symptoms occurs in that insti- 
tution. Although the histories of some of the cases in the asylum lent 
support to the theory that an acid is the active agent in causing rachitis, 
others did not so readily admit of this explanation, and it seemed to us 
that the etiology of this disease required further elucidation. It is certain 
that general anti-hygienic conditions are a common predisposing cause, 
even if lactic acid be the direct or exciting cause. 

Anatomical Characters. — For convenience of description rachitis is 
divided into three periods, 1st, That of altered nutrition ; 2d, That of 
curvature and deformity ; and 3d, That of reconstruction. 

The growth of bone occurs from the epiphyseal cartilage, and from the 
periosteal or fibrous membrane which surrounds and protects bone ; growth 
in leno-th is from the former, in thickness from the latter. In the normal 
DTOwth of bone from the epiphyseal cartilage, there is first, beginning 
at the distal end of the epiphyses, a white zone of cartilage, consisting 
of the hyaline matrix containing the usual cartilage cells. Underneath 
this, and nearer the bone, is the ' k zone of proliferation," the cartilage in 
which becomes softer from the formation of cells, and absorption of the 



KACHITIS. 109 

matrix. Eacli cartilage cell divides into two cells, and each of these 
cells divides into two other cells, and the division is repeated so 
that eight cells instead of one are inclosed in a common cavity and cap- 
sule. Each capsule is distended by this proliferation of cells and swell- 
ing of each cell. Near the bone, that is alono- the extremity of the 
diaphysis, the groups of cells inclosed in their capsules nearly touch each 
other, the matrix having been absorbed. The end of the bone is covered 
by one or two layers of these groups of cells about to undergo ossification. 

In rachitis the state is different. The cells still inclosed in their cap- 
sules undergo a more frequent division, so that instead of six or eight in 
the average, there are as many as thirty or forty in each capsule. Besides 
the layers of capsules are many more than in health, so as to form a con- 
siderably deeper zone. Hence, while in the normal bone the proliferating 
zone appears to the naked eye as a very thin, scarcely perceptible, layer 
of a reddish-gray color, tipping the end of the diaphysis, it is in rachitis 
a broad cushion, very soft, and of a grayish, translucent appearance, with a 
zone of cartilage more nearly normal on the distal end, and the proximal 
end lying upon the extremity of the diaphysis. This exaggerated cell 
proliferation and corresponding absorption of the hyaline substance inter- 
vening between the groups of cells cause the well-known softening and 
swelling of the cartilage, and enlargement of the joint. While this oc- 
curs, the ossifying process is also arrested. "VYe indeed observe an effort 
in the direction of bone-formation. The Haversian canals, surrounded by 
capillary loops, extend from the bone into the proliferating zone of cartil- 
age. Their extension is effected by absorption of the basic substance, 
and the appropriation of the cavities containing groups of proliferating 
cells, which lie in their way, and which have been described above. Be- 
fore the annexation of these cavities to the Haversian canals, the cells 
which they contain become much smaller (medullary cells) by a rapid 
division. We also find as farther evidence of the attempt at bone-forma- 
tion granules and masses of lime scattered through the cartilage, and here 
and there spicuke and nodules of true bone springing up from the bony 
substratum of the shaft. Some of the Haversian canals extend far into 
the cartilage, nearly indeed to its free surface ; but most of them extend 
only into its lowest portion. 

The development of bone occurs from the under surface of the peri- 
osteum. In health a soft " vascular germinal tissue" springs from the 
periosteal surfaces, and rapidly receives lime salts, and is transformed 
into bone. It always remains a thin substratum, barely visible, separat- 
ing the periosteum from the bone. In rachitis this germinal tissue, not 
undergoing, or undergoing slowly and imperfectly, the osseous transforma- 
tion, becomes a thick layer. Its color and appearance are like spleen 
pulp, so that the older observers supposed that there was a lnemorrhao-ic 
extravasation between the periosteum and bone. There is, however, no 



110 RACHITIS. 

extravasation, unless it accidentally occur from the numerous delicate capil- 
laries. The resemblance to extravasatcd blood or spleen pulp is due to 
the abundant growth of large and thin-walled capillaries, as shown by the 
microscope. This layer of germinal tissue is, for the most part, quite uni- 
form over the diaphyses of the long bones, while upon the cranial bones 
it is much thicker in certain localities than in others, and over certain 
areas it appears nearly or quite normal. 

The nisus of ossification also appears in this sub- periosteal tissue. 
Lime salts are scantily and loosely deposited through it, forming rather 
osteophytes than bone, of very loose texture, thick, vascular, and fragile. 

The question is naturally suggested, how does this disease affect the 
bone which is already formed when the rachitic state commences ? Vir- 
chow's answer is the following : " Rachitis has, as you are aware, by 
more accurate investigation, been shown to consist, not in a process of 
softening in the old bone, as it had previously generally been considered 
to be, but in the non-solidification of the fresh layers as they form ; the 
old layers being consumed by the normally progressive formation of 
medullary cavities, and the new ones remaining soft, the bone becomes 
brittle." (" Cellular Pathology," Lect. 19). 

But this opinion of Virchow certainly requires modification. There 
is more or less absorption of the lime salts independently of that 
which normally occurs in the development of bone, as has been shown 
by Heitzman's experiments. Moreover, in craniotabes, which is 
one of the most interesting manifestations of the rachitic disease, 
the calcareous absorption is so great that holes appear in the skull. In 
this connection it is proper to consider the pathology of rickets. What 
is the nature of this malady ? Niemeyer, I think, expresses the correct 
view when he says, " It seems to me that the most probable hypothesis 
regarding the cause of rachitis is that which refers it to inflammation of 
the epiphyseal cartilage and periosteum " (Article rachitis). The 
increased vascularity of the periosteum, the proliferation of periosteum 
and cartilage, the tenderness and pain on motion, and the febrile move- 
ment in acute cases, indicate inflammation rather than any other recognized 
pathological state. Rachitis appears to be a chronic, subacute inflamma- 
tion, presenting an analogy with certain other well-known forms of inflam- 
mation, as cirrhosis, and chronic nephritis, in which proliferation of con- 
nective tissue and sclerosis occur. The eburnation rather than ossifica- 
tion, which terminates the rachitic process, may be considered an osteo- 
sclerosis. 

In severe cases of rachitis many bones are affected. Indeed there is no 
bone that is not liable to the rachitic change ; but in mild cases only a 
few are involved, at least so as to produce deformity appreciable to the 
sight. 

Second Stage. — The second stage is that of curvatures and deformity. 



RACHITIS. Ill 

In typical cases the relative proportion of calcareous matter being greatly 
reduced, if an opportunity occur of examining the skeleton, the Jong bones 
can be bent and their epiphyses, as well as the flat and short bones, can 
be compressed, and in some instances even crushed between the thumb 
and fingers. " The bones in this state can be cut with a knife with as 
much ease," says Trousseau, " as a carrot or other soft root.'" In cases 
in which the deposition of lime salts has been almost totally arrested for 
a considerable time, while absorption has occurred to give passage to the 
newly-formed canals, if the bone removed from the cadaver be dried, it 
will be possible to respire through it, so great is its porosity, and its 
weight is from six to eight times less than that of normal bone. 

The head of the rachitic child appears abnormally large ; but this ap- 
pearance is due in great part to the delayed growth of the facial bones. 
Ritter von Rittershain states that accurate measurement shows that the 
rachitic head is not larger than that of the healthy child. But more re- 
cent examinations show that the head of the rachitic is abnormally large. 
At a recent discussion in the London Pathological Society, reported in 
the London Lancet, vol. ii., p. 1017, 18S0, it was stated that in seventeen 
rachitic cases with an average age of 4 # 72 years, the average circumference 
of the head was 21 -22 inches, while in an equal number of non-rachitic, with 
an average age of 6*5 years, the average circumference was 19-95 inches. 
Shaw has shown that the proportionate size of the head to the face, which in 
health is as six to one, is in rachitis as seven and one thirteenth to one. If 
the disease commence in the first year, or the beginning of the second, the 
delayed ossification prevents closure of the anterior fontanelle, which in 
the normal state ordinarily becomes ossified by the fifteenth month. In 
the rachitic the fontanelle may remain open through the second or even the 
third year, and the sutures proceeding from it also remain open longer 
than in health. 

The rachitic head does not always present the same shape. It may be 
elongated, but more frequently it approximates to a square shape. It is 
more or less flattened superiorly, laterally, anteriorly, and posteriorly. 
The sutures which are late in closing are commonly depressed, while the 
frontal eminences are unusually elevated. After recovery the fontanclles 
and sutures often remain depressed below the general level, the latter 
appearing as grooves. 

Craniotabes. — Occasionally the cranial bones in rachitis become very 
much thinned, and softened in places, to which the name craniotabes has 
been applied. This thinning occurs most frequently in the occipital and pari- 
etal bones, and sometimes to such an extent that the dura mater and peri- 
cranium are in contact. The soft spots are yielding when pressed upon, and 
in the cadaver, they are seen to be translucent when held to the light. 
Senator says, " The thinning of the occipital bone is brought about by 
the contending pressure of the pillow from without, and the brain from 



112 



RACHITIS. 



within, when the infant is lying on its back." This is the accepted 
explanation of the cause of craniotabes. since it occurs in those portions 
of the skull upon which the pillow presses. It occurs chiefly in infants 
under the age of eight months, but, as we have seen, it may be congenital, 
the result of deficient ossification in the foetal state. The degree of 
craniotabes varies greatly in different patients. There may be simple 
depressions, like erosions, on the inner surface of the occipital and parietal 
bones, while in other cases, and such as have been particularly studied 
by physicians, the loss of bone is complete, producing holes or open spaces 
of greater or less extent, so that the brain is covered only by the meninges, 

Fig. 6. 




CASE IN THE NEW YORK INFANT ASYLUM. 



pericranium, and scalp. In order to ascertain if craniotabes exist, 
the examination must be made away from the sutures, for in the rachitic 
the margins of the cranial bones are flexible and yielding, even when 
there is no thinning, but thickening from cartilaginous proliferation. Pres- 
sure should be made cautiously and lightly with the fingers, so as not to 
injure the unprotected brain. When the bony layer is lacking the sensa- 
tion communicated to the fingers has been compared to that from press- 
ing upon a fully distended bladder. 

Pressure upon the exposed brain is badly borne. Consequently the 
craniotabic infant lying in the usual position does not have quiet and 
refreshing sleep. It wakes often and frets till it is taken in the nurse's 
arms, or placed over her shoulder, which relieves the pressure upon the 
brain. Sometimes it instinctively seeks a position for its head on the 
edge of the pillow with the face downward. All rachitic infants are 
fretful, but those with craniotabes are most so of all from the mechanical 
cause alluded to. But if mere fretfulness were all, craniotabes would 



DEFORMITIES. 113 

possess much less pathological significance than belongs to it. Since the 
time of Elsasser it has been known to sustain a causative relation to many 
cases of that neurosis which has been variously designated spasm of the 
glottis, internal convulsions, laryngismus stridulus, and Kopp's asthma. 
Disturbance of the function of the brain, consequent on its exposed state, 
greatly increases the liability to convulsive diseases, and laryngismus stri- 
dulus is the one to which craniotabic infants are especially liable. For 
further particulars relating to this dangerous neurosis the reader is referred 
to the chapter which treats of it. 

The wood-cut on the preceding page is of a child with rachitis, now in 
the N. Y. Infant Asylum. It is 18 months old, has six teeth, a square 
head, softened and thin cranial bones, and a greatly depressed longitudinal 
suture. Within the last two months it has had attacks of internal con- 
vulsions, in which it holds its breath and fixes its eyes, but which pass 
off in probably a quarter of a minute, without any noise. This child is 
very fretful, and dreads to be approached. In the same institution is 
another child, aged 15 months, without teeth, with a less marked rachitic 
head, but with the rachitic rosary, and a decided enlargement of certain of 
the joints of the extremities. 

The deformities of the trunk and limbs occurring in the second stage 
are interesting. There is lateral depression of the thoracic walls between 
the second or third and ninth ribs, accompanied by projection of the 
sternum. The shape of the chest resembles that of the prow of a ship, 
to which Glisson likened it, or the breast of a bird. This deformity is 
the result of atmospheric pressure, occurring externally upon the thoracic 
walls during inspiration, at the time when the ribs are most softened, and 
least elastic. Depression of the first and second ribs is partially prevented 
by the support which they receive from the clavicles. The length of the 
clavicles is, however, somewhat diminished, and their curvatures in- 
creased, so that the shoulders approach each other. Below the ninth 
ribs the thoracic walls are expanded ; the corresponding ribs on the two 
sides arc more separated from each other than in their normal state. The 
expansion of the base of the chest diminishes the convexity of the dia- 
phragm, and causes depression of the liver and spleen. 

The abdomen in rachitis is protuberant, partly on account of the de- 
pression of the liver and spleen, partly on account of the spinal curva- 
tures and shortening of the trunk, but chiefly on account of the fact that 
in this disease the intestines are distended with gas. The meteorism 
gives rise to tympanitic resonance on percussion, except occasionally over 
the lower part of the abdominal cavity, where there may be dullness from 
serous effusion. 

Spinal curvatures, to which allusion has been made, are common in 
rachitis. They are due to softening of the intervertebral cartilages, and 
the bodies of the vertebrae, and to laxity of the intervertebral ligaments. 



1U 



RACHITIS 



Their direction is commonly antero-posterior. They are distinguished 
from the deformity of caries by the absence of an angular projection. 
Moreover, except in cases of long continuance, the curvature can be re- 
moved by placing the patient in a horizontal position, and pressing with 
the fingers on the projecting parts. The pelvic bones also undergo change 
of shape. The deformities of these bones, resulting from rachitic soften- 
ing, are in the female the most important of any which the skeleton un- 
dergoes. They are produced by pressure from above of the abdominal 
organs and the spinal column. While the brim of the pelvis may be 
widened by the pressure of the abdominal organs, the promontory of the 
sacrum is carried forward and downward by the weight of the spinal col- 
umn, which supports the head and shoulders. Pressure from below of 
the heads of the thigh-bones in standing, and of the ischia in sitting, tends 
to narrow the outlet of the pelvis. Hence the marriage of the female who 
has been rachitic in infancy may involve serious consequences. Many of 
the tedious and instrumental labor cases in the families of the city poor, 
which severely tax the patience and endurance of young practitioners, are 
attributable to rickets in early life. 

The bend of the humerus is such in most patients that its concavity 
looks inward and forward, but occasionally it is directly the opposite. 
The concavity upon the forearm corresponds with the palmar surface of 
the hand. The concavity of the thigh presents toward the median line 
and a little posteriorly, the natural bend of the femur being simply in- 



Fig. 7. 



Fig. 8. 





creased. The curvatures of the tibia and fibula vary in different cases. 
If the infant have not walked, their concavity is sometimes directed for- 
ward and inward ; but if it have walked, outward and backward. Occasion- 
ally, the direction of the bend on one side differs from that on the other. 



DEFORMITIES. 115 

Third Stage. — The third stage is that of reconstruction. After a vari- 
able period, depending on the severity of the disease and the state of the 
constitution, the " vascular germinal tissue' 1 becomes more consistent, 
and points of calcareous matter appear here and there within it. The de- 
posit of lime-salts continues, and the newly formed bone again becomes 
firm and unyielding. It is generally cancellous in places where the original 
bone was of this character, though the extent of the new cancellous struc- 
ture is apt to be different from that in the normal bone. Thus not only arc 
the epiphyses cancellous in the new as in the original bone, but I have, 
seen the entire medullary cavity filled with cancellous structure. The 
subperiosteal deposit is sometimes also transformed into cancelli. This 
was the character of the change occurring under the pericranium in one 
specimen which I examined. Where the original bone was compact, the 
reconstructed bone is usually of the same character, as, for example, in 
the shafts of the long bones. Compact portions of the reconstructed 
skeleton have been said to lack the elements of true bone ; they are osteoid, 
according to this theory, and not osseous, resulting from petrifaction of 
the gelatiniform substance. I have, however, found the elements of true 
bone in the skeletons of two individuals who had well-marked rachitic curva- 
tures. The portions examined were removed from the concavities of the 
long bones, where there had been decided bending and thickening of the 
shafts from the large amount of rachitic deposit. In both specimens the 
osseous corpuscles (lacuna?) and Haversian canals were easily demon- 
strated ; but in both there had been considerable growth of the bones 
since the rachitic period, and perhaps the portions which w r ere examined 
belonged to this subsequent growth. The deposit of lime salts which 
occurs during convalescence ordinarily produces a firmer and more', con- 
densed structure than normal bone. It is sometimes designated eburnation: 

Such is a brief sketch of the changes which the skeleton undergoes in 
ordinary cases of rachitis. An extreme degree of softening may be 
reached in four or five months, or not till the lapse of a year or more. 
The third stage, or that of consolidation, lasts one or two years. While 
in the first and second stages there is an arrest of ossification, and a de- 
ficiency of calcareous salts in the system, there is often in the third stage, 
as Lebert has stated, an exuberance of ossification, and a superabundant 
deposit of the salts of lime, so that the reconstructed bone is firmer and 
stronger than normal bone. 

Occasionally, in reduced states of system, the third stage does not 
occur. The bones remain very soft and flexible, consisting almost entirely 
of animal matter. This is what has been designated rachitic consumption 
of bones. Such cases end fatally after a variable time. 

A not infrequent accident in the second period of rachitis is fracture in 
the shafts of the long bones. From the nature of the fracture, crepitation 
can rarely be produced. The callus is not generally abundant, and reunion 



116 RACHITIS. 

of the bone is slow. Many cases of rachitic fractures are partial, portions 
of the shaft deprived of the mineral element bending, while the part which 
retains this element is fractured. 

Rachitis retards the evolution of the teeth. If the disease commence 
as early as the fifth or sixth month, no teeth commonly appear till after 
the age of twelve months ; if certain teeth have appeared prior to the 
rachitic disease, an interval of several months elapses before the next are 
cut. Sir William Jenner states that if the child have no teeth by the 
ninth month, it is probably rachitic. Teeth which are developed during 
the rachitic state are frail, and deficient in enamel. They become black 
and carious early, and loosen in their sockets. If there be no tooth at the 
age of twelve months, the infant is probably rachitic. The fontanelles 
and cranial sutures remain open longer than in healthy infants. The for- 
mer may not close till the third or fourth year, and the latter not till the 
second or third year. Patency of the anterior fontanelle after the age of 
twenty months indicates rachitis. 

Rickets produces another- important effect upon the skeleton. Its growth 
is stunted, with the single exception perhaps of the cranial bones, so that 
those who have been rachitic in childhood, unless mildly, have less stature 
in adult life than the average. This is evident, though ample allowance 
be made for curvatures. The arrest of development is greater in some 
bones than others. It is greatest in the bones of the face, pelvis, and 
lower extremities. Stunted growth of the pelvis in connection with de- 
formity may obviously involve very serious consequences in the female. 
Although the prominent and characteristic lesions pertain to the skeleton, 
the soft tissues are also more or less implicated. The ligaments become 
relaxed and flabby, giving unusual mobility to the joints and unsteadiness 
to the movements. The fibrous bands which unite the vertebrae, as well 
as the ligaments of the extremities, participate in the relaxation. 

In certain rachitic patients the muscles, either in consequence of malnu- 
trition, due to indigestion, or intestinal disease, or in consequence of disuse 
• — for the rachitic are apt to be quiet — become shrunken and flabby. The 
spleen is frequently enlarged, as ascertained by palpation and percussion. 
The enlargement is the result of cellular proliferation, which is common in 
diseases attended by dyscrasia. The liver in many patients undergoes no 
perceptible change, except that it may be crowded a little downward. In 
occasional cases it is enlarged from fatty infiltration, but no special signi- 
ficance attaches to this, for fatty liver is common in various forms of dis- 
ease attended by innutrition and wasting. There can be little doubt that 
Sir William Jenner errs when he states that albuminoid infiltration of the 
liver is common in rachitis. Parry, Gee, Dickenson, and Senator agree 
that it is rare, and if it do occur, is a coincidence. 

Symptoms. — The patient in incipient rachitis is quiet and melancholy., 
shunning caresses or attempts to amuse him, since movement of his body 



SYMPTOMS. 117 

increases his suffering. He has general tenderness, due in part to the 
morbid state of the periosteum, and in part to hyperesthesia. The rachitic 
infant, therefore, unless very mildly affected, will evince anxiety and 
dread even at the approach of any one, through fear of being touched or 
moved. Trousseau says : " This change in the character of the infant, 
the fear which it experiences of seeing its sufferings return, which the 
pressure of another's hand causes, this habitual sadness impressed upon 
its features, differs from that which we observe at the commencement of 
other maladies, especially from that in the prodromic period of cerebral 
fevers. In truth, in an infant over whom this last and cruel affection is 
impending we are able to excite again a momentary cheerfulness ; we are 
able, by exciting actively its spirits, to make it turn temporarily from this 
melancholy languor, which constitutes its habitual state. It is not thus 
in the rachitic ; the more you desire to arouse it, the more you solicit its 
movements, the greater will be its impatience. It is indifferent to the 
plays which it previously loved. This . . . habitual sadness in an 
infant, who, with an appetite rather augmented than diminished, sensibly 
emaciates, who has constantly acceleration of pulse coincident with pro- 
fuse perspiration, these symptoms, I repeat, have positive significance 
when the infant docs not cough or present any of the signs which induce 
us to believe in the occurrence of tubercular phthisis. " 

Febrile movement, manifested by acceleration of pulse and increased 
heat of blood, sometimes occurs in the more acute eases, but in the ordi- 
nary chronic cases there is commonly no decided elevation of tempera- 
ture. 

A bruit de soufflet of greater or less intensity, synchronous with the 
pulse, has frequently been heard in rachitic cases, when the ear was ap- 
plied over the anterior fontanelle. Drs. Fisher and Whitney, New Eng- 
land physicians, first called attention to this murmur, believing it to be a 
sign of chronic hydrocephalus. MM. Rilliet and Barthez heard it in 
cases of rachitis, and therefore concluded that the American observers 
had mistaken the rachitic for the hydrocephalic head. Later observa- 
tions have established the fact that this murmur possesses little diagnostic 
value. It is heard in healthy as well as diseased infants. Dr. Wirthgen 
detected it 22 times in 52 children, all of whom, except four, were in 
good health. I have auscultated the anterior fontanelle in 29 infants, who 
were, with two exceptions, between the ages of three and thirty months. 
They were in good health, or with trivial ailments which would not affect 
the cerebral circulation. In most infants with a patent fontanelle a mur- 
mur can be distinctly heard synchronous with the respiratory act, and in 
15 of the 29 cases no other bruit could be detected, while in the re- 
maining 14 abruit synchronous with the pulse was heard at the fontanelle. 

The rachitic, as stated above, are liable to perspirations, which are pro- 
fuse about the head and neck, so as to moisten the pillow on which they 



118 RACHITIS. 

lie. The respiration is more or less accelerated except in the mildest 
cases, in consequence of the flexibility and diminished elasticity of the 
ribs, and the lateral depression of the thoracic walls, which prevent full 
inflation of the lungs. 

The urinary secretion is abundant, like the perspiration. During the 
first and second periods it contains a large amount of the calcareous salts, 
since the lime which enters the system with the ingesta, and which in 
the normal state is expended in the growth of bone, is eliminated from 
the system by the kidneys. 

The appetite in the beginning of rachitis is good, sometimes even better 
than in health ; but it gradually diminishes, as the disease increases in 
severity. Diarrhoea, alternating with constipation, is common. With the 
continuance of febrile movement and loss of appetite the patient soon be- 
gins to lose flesh, emaciation in the second stage being a prominent 
symptom. 

Complications. — Rachitis is often attended by certain serious complica- 
tions, the most frequent of which are inflammatory affections of the 
respiratory apparatus. Bronchitis is one of the most common diseases 
during the age at which rachitis occurs, and even a mild form of it in- 
volves oreat danger if the ribs be soft and flexible or the thorax have the 
rachitic deformity. In these cases, since full inflation of the lungs is pre- 
vented, collapse, more or less complete, of certain of the lobules is apt to 
occur, increasing the amount of dyspnoea, and therefore, diminishing the 
chances of recovery ; hence bronchitis is very fatal in infants who are 
decidedly rachitic. 

Imperfect digestion of food, and unhealthy alvine evacuations, common 
in rachitic children, frequently cause diarrhoea, and, after a time, intes- 
tinal inflammation. The diarrhoea, especially if it have become inflamma- 
tory, is apt to be obstinate and dangerous, the patient becoming emaci- 
ated and feeble. 

Internal convulsions, the so-called laryngismus stridulus, has been ob- 
served in so large a proportion of cases, that its occurrence in rachitis, 
especially in craniotabes, must be considered something more than a coin- 
cidence, as has been stated above. Hypertrophy of the brain, and chronic 
hydrocephalus, are also occasional complications. In cases of great deform- 
ity of the chest from rachitis, in which the lungs are more or less com- 
pressed, the pulmonary circulation is retarded and imperfect. This gives 
rise to congestion of the right cavities of the heart, with hypertrophy of 
this organ, and congestion of the hepatic veins, liver, and portal system. 
Congestion of the portal system may be regarded as one cause of the 
diarrhceal attacks. 

Diagnosis. — Diagnosis is easy, except in incipient or slight cases. 
The lesions which pertain so largely to the skeleton are readily detected. 
Beading of the costo-chondral articulations occurs early, and is apparent 



PEG GNOSIS — TREATMENT. 119 

to the sight. Enlargement of the joints of the limbs, arrested dental 
evolution, the state of the anterior fontanelle, the peculiar shape of the 
head, the sternal projection, and rachitic curvatures, indicate positively 
the rachitic state. Profuse perspiration upon the head and neck, and the 
o-eneral tenderness of the patient, as evinced by his cries when moved or 
disturbed, are also important diagnostic signs. Nevertheless rachitis, though 
not uncommon in the tenement house families of New York, is frequently 
overlooked by physicians, who attribute tin fretfulness, perspiration, 
etc., to other causes. Backwardness of dentition is a notable sign of 
rachitis, and is therefore one of the most important for diagnosis. 

Prognosis. — The prognosis is favorable, as regards life, if rachitis be 
recognized at an early period, and properly treated. The vicious nutri- 
tive process may be arrested, and the patient recover with but slight de- 
formity. If curvature of the long bones have occurred, and the head and 
thorax be misshapen, the patient, under favorable hygienic conditions, 
commonly recovers from rachitis, but with permanent deformities. 

If there be that degree of spinal curvature in the dorsal region, and de- 
pression of the ribs, that respiration is, habitually, more or less accelerated 
and embarrassed, on account of compression of the lungs, the prognosis is 
unfavorable, since bronchial or pulmonary inflammation, occurring in this 
condition, is apt to be fatal. If there be much emaciation, and especially 
if diarrhoea be present, or of frequent occurrence, the prognosis should be 
guarded. In these cases there is probably waxy degeneration of important 
organs, which cannot be remedied. 

Treatment. — The correct treatment of rachitis is obvious when we 
consider its character and the nature of its causes. The indication is to 
restore healthy nutrition. This requires both hygienic and therapeutic 
measures. The apartment in which the child resides should be dry, airy, 
and plentifully supplied with light. He should be taken daily into the 
open air, in order to invigorate his system, but in such a way as not to 
increase his suffering, in consequence of his general tenderness. The 
diet should be appropriate for he age. It should be bland and easy of 
digestion, and, at the same time, sufficiently nutritious. Cleanliness of 
person and apartment, and clothing sufficient to protect from vicissitudes 
of temperature, are requisite. The rachitic patient of the city should, if 
practicable, be removed to a well-selected locality in the country. 

The medicines which are of undoubted efficacy in rachitis are cod-liver 
oil and lime. I prefer the following formula, which agrees with most 
children : 

I£ . 01. morrhuoe, r vj ; 

Syr. calcis lactophosphatis, 
Aq. calcis, aa r iij. Misce. 

Give one to two teaspoonfuls three or four times daily. To it may be added 
the syrup of the iodide of iron. The ordinary ferruginous and vegetable tonics 
are all useful. 



120 SCROFULA. 

The compound syrup of the phosphates, the citrate of iron and quinia, 
wine of iron, iodide of iron, the various preparations of cinchona, co- 
lumbo, etc., are the medicines which, with or without cod-liver oil, are 

best calculated to restore healthy nutrition. When complications arise, 
the treatment should be modified to meet the exigencies of the case. 
Most of the diseases which occur as complications, require treatment 
similar to that which is appropriate in their idiopathic form, but all meas- 
ures of a depressing nature should be avoided. 



CHAPTEE II. 

SCROFULA. 



The term scrofula (scrofa, a pig, from the resemblance of the enlarged 
cervical glands of a scrofulous individual to a swine's neck) is applied to 
a diathesis which is characterized by increased vulnerability of the 
tissues. The nutritive process of the tissues is readily disturbed even by 
trifling irritants or agencies in those who possess this diathesis, and, 
therefore, the scrofulous are very prone to inflammations of various parts 
and to hyperplasia, more particularly of the lymphatic glands. Inflam- 
mations which can properly be considered as dependent upon this dia- 
thesis, or as occurring under its influence, are for the most part subacute 
or chronic, and they differ from ordinary inflammations in the fact of a 
greater cell formation, and greater liability to cheesy degeneration of inflam- 
matory products, so that return to the healthy state by absorption is slow 
or impossible. Moreover, this diathesis, while it gives rise to certain in- 
flammations, which do not occur or are rare in other states of the system, 
and which all physicians at once recognize as scrofulous, often modifies 
those common inflammations to which all persons, whether scrofulous or 
non-scrofulous, are liable, as coryza and bronchitis, rendering them more 
protracted and less amenable to the ordinary treatment. 

Scrofula is a disease chiefly of infancy and childhood. Manhood, 
especially the first years of it, is not entirely exempt, but scrofulous mani- 
festations after the age of twenty years are feeble and infrequent, disap- 
pearing entirely as the individual advances toward middle life. The dia- 
thesis is most active prior to the age of ten years. 

Causes. — Scrofula is congenital or acquired. Parents who had scrofu- 
lous symptoms in early life, or who are in a state of decided cachexia, as 
from cancer, syphilis, intermittent fever, or tuberculosis, are apt to beget 
scrofulous children. Insufficient nourishment of the mother during a 
considerable part of her gestation, and advanced age, and therefore fee- 
bleness, of the father, are occasional causes. Near blood relationship of 



CAUSES. 121 

the parents is also a recognized cause, and to this has been attributed the 
scrofula of royal families. Children whose father and mother are first 
cousins are, according to my observations, apt to be scrofulous. 

Again, those born with sound constitutions may acquire scrofula though 
anti-hygienic influences in the first years of life. Among the poor of 
New York we often observe one child in the family who presents scrofu- 
lous symptoms, while the rest of the children are well, and in many cases 
we are able to trace back the diathesis to some depressing cause or causes, 
which were sufficient to effect the peculiar change in the molecular condi- 
tion of the tissues which constitutes this disease. Obviously the causes 
of acquired scrofula are quite numerous. In the infant i't is sometimes 
produced by insufficiency or poor quality of the breast-milk, or the 
use of artificial food during the period when breast-milk is required. Too 
protracted lactation also, especially if artificial food be almost wholly 
withheld, may cause it ; as may also, in those who have passed beyond 
the age of lactation, the continued use of a diet which is deficient in 
nutritive properties. 

Residence in damp, dark, and filthy apartments or streets may also 
produce it. Hence one reason of its frequent occurrence among the city 
poor. Residence in a small, crowded, and imperfectly ventilated apart- 
ment has been known to produce it, even with personal cleanliness, and a 
diet sufficiently nutritive. 

Scrofula may also be caused, in those previously robust and of sound 
constitution, by disease of an exhausting nature. The eruptive fevers, as 
smallpox, measles, and scarlet fever, if severe, occasionally produce this re- 
sult ; or they render active the diathesis, which had hitherto been latent. 
In this city, where chronic entero-colitis of infancy is common, I have 
sometimes been able to trace the diathesis to it. 

Can a child affected with scrofula communicate it to others ? Does 
scrofula possess a specific principle, a virus which produces the dis- 
ease, and which is communicable to others ? There is a strong popu- 
lar belief that it is contagious by contact, and some good patholo- 
gists and high authorities in children's diseases are inclined to be- 
lieve that this opinion has foundation in fact. M. Bouchut, who holds 
that the " scrofulous and tubercular diatheses are identical," says of 
scrofula that it has not been shown to be inoculable. " Nevertheless, if 
its contagiousness have not been demonstrated, we are not able to say that 
it will not be some day. The facts of vaccinia followed by impetigo, by 
scrofulous ophthalmia, and enlargement of the cervical glands attributed 
to the inoculation of scrofulous vaccine virus, and those of the contagion 
of phthisis by constant cohabitation, demand, at least for the present, a 
certain reserve." 

But scrofula differs widely in its nature from those diseases which are 
known to be communicable. It presents no analogy with them. We 



122 SCROFULA. 

would not suppose, apart from observations, that a diathesis which consists 
in such a state or constitution of the tissues that the}- are easily wounded 
possessed any inoculable principle, and in my opinion observations go to 
show that no such principle exists. How often do we observe children 
with scrofulous coryza, otorrhcea, or scrofulous cutaneous eruption, associat- 
ing with others without communicating the diathesis ? 

Vaccination, however, affords the best opportunity for determining 
whether scrofula is inoculable, and the very prevalent opinion of non-pro- 
fessional people, that it may be communicated and established through 
this operation, should have due weight ; for it may be stated, as a rule, 
that a widespread popular belief in reference to a disease which has ex- 
ternal manifestations, does have some foundation in truth. 

The following are the facts in reference to this matter : 

1st. It is the almost unanimous opinion of the most experienced vacci- 
nators that pure vaccine lymph taken from a vesicle prior to the eighth 
day, never communicates anything but vaccinia. When another disease, 
as syphilis, is communicated by the use of the lymph, it is through the 
blood, which has been mixed with the lymph by careless puncture of the 
vesicle. This opinion, so strongly established by observations, also com- 
mands assent from its reasonableness. 

2d. Vaccination of those who are decidedly scrofulous with virus from 
a healthy child, especially if the scab be employed, not infrequently 
produces a sore which becomes covered with a thick and irregular crust, 
consisting in part of inspissated pus, and the sore is long in healing. In 
the scrofulous, also, impetiginous eruptions are apt to arise around the 
vaccine sore, and the axillary glands to become tumefied on the side cor- 
responding with the vaccination. This gives rise to the belief on the part 
of friends that impure virus has been used, and scrofula communicated, 
while the fault is in the constitution of the child itself. The tumefaction 
of the glands, and the primary and secondary sores gradually disappear in 
most cases, leaving no ill effects, and with no subsequent manifestation* 
of disease. 

3d. The vaccine crust from a decidedly scrofulous child, as it contains 
more or less animal matter, and is often pale, irregular, or broken, in- 
serted in the arm of a healthy child, not infrequently produces an imme- 
diate inflammation with suppuration, so that the vaccine vesicle, if it 
form, is soon broken, and an irregular sore and crust result, which 
present none of the appearances observed in the uncomplicated vaccine 
eruption. A simple inflammation, produced by the pus or other products 
contained in the scrofulous scab, has coexisted with and modified the 
specific eruption. The sore heals gradually, and impetiginous eruptions 
may occur around it, but no struma remains or is communicated. 

4th. Scrofulous manifestations sometimes appear for the first time 
after vaccinia, but they appear also after those analogous but severer erup- 



CAUSES. 123 

tive fevers, namely, measles, scarlet fever, and smallpox. Those infec- 
tious exanthematic diseases which profoundly affect the constitution, it is 
admitted, may be a co-operating, if not a main, cause of scrofula, and is 
there anything - unreasonable in the supposition that vaccinia may have oc- 
casionally a similar effect, though less frequently or in a less degree, in 
proportion as it is milder ? From my own observations, I am of opinion 
that vaccinia, not vaccination, may occasionally awaken to activity the 
scrofulous diathesis, or, in combination with other causes, may even pro- 
duce it in those who previously possessed good constitutions. It is a 
well-established fact, in the etiology of diseases, that causes which, in 
themselves, are entirely inadequate, or even insignificant, frequently produce 
disease in a system which other agencies have already prepared for it. 
Thus an excoriation gives rise to erysipelas, or a slight exposure to cold 
produces rheumatism. In like manner in those cases in which the friends 
have charged the production of scrofula upon vaccination, it has seemed to 
me that the most that could, with truthfulness, be alleged, was that the con- 
stitutional disease, vaccinia, which had been produced by the operation 
was a subordinate, but, under the circumstances, a sufficient co-operating 
cause of the scrofulous state. 

The following is the most striking case of the apparent communication 

of scrofula through vaccination which I have met : D , West Fortieth 

Street, residing in a tenement house, had no scrofulous affection, and was 
considered healthy till the age of eleven years. The remaining children 
of the family have never exhibited scrofulous symptoms. At the age of 
eleven years this boy was vaccinated from a scab, the source of which 
was not known, but by a physician whose practice was chiefly among the 
city poor. The sore produced was long in healing, and, before it had 
healed, the axillary glands, and those of the face and neck, began to 
be prominent and hard. From this time to the present, a period of six 
years, these glands have remained so large as to constitute a deformity, 
and certain other groups of glands, as those in the left infra-clavicular 
legion and right groin, have undergone a similar hyperplasia. Examina- 
tion of the blood by the microscope shows the absence of leucocytlnemia. 
This case, at first view, certainly appears to be an example of the commu- 
nication of scrofula through vaccination, and, for a time, I could inter- 
pret it in no other wav. But, when we recollect the facts already stated, 
namely, the improbability of the communicability of a diathesis of such a 
nature, how frequently scrofula is acquired by children of the tenement- 
house population, solely through the anti-hygienic conditions in which 
they live, the large number of scrofulous children in the crowded quarters 
of the poor, many of whom have external ailments, so that the conditions 
for communication are present in a high degree if scrofula were conta- 
gious, while the instances of its apparent communication are verv infre- 
quent, is it not probable that cases like this are to be explained in the 



124 SCROFULA. 

manner indicated above, and that scrofula is not transmissible by vaccina- 
tion ? 

The close resemblance clinically of scrofulous affections with the ulterior 
lesions of syphilis, has been adduced in support of the belief that scrofula, 
like syphilis, is due to some undiscovered specific principle. But the 
parallelism, it seems to me, is more apparent than real, and the differ- 
ence between the two diseases is so great as to destroy the validity of the 
argument. For while syphilitic manifestations result from the reception 
of a certain poison in the system, scrofula as certainly results from a 
variety of ordinary depressing agencies, affecting the system in so many 
distinct ways that it seems unreasonable to suppose that they pro- 
duce a fixed specific principle, which, remaining in the system, causes the 
phenomena of scrofula. The facts then appear to justify the belief that 
scrofula does not possess any such principle, but that this constitutional 
anomaly is the direct result of the action of depressing agencies on the 
constitution of the tissues. 

The primary scrofulous ailments, by which the diathesis is manifested, 
occur for the most part upon one of the free surfaces, namely, upon some 
part of the skin or mucous membrane. Certain standard authors attribute 
this to the fact that these parts are most exposed to the action of noxious 
agencies. The lymphatics lying in the inflamed area take up the altered 
lymph and carry it to the adjacent lymphatic glands, which become irri- 
tated, and undergo hyperplasia, and perhaps ultimately suppuration. This 
is, in a large proportion of cases, the beginning of scrofulous ailments. 
Nevertheless, in not a few instances, the first manifestations are in deep- 
seated and covered parts, as when scrofulous periostitis or osteitis occurs, 
without any peripheral lesion. 

Anatomical Characters. — There are no ascertained anatomical 
changes in the blood which are peculiar to scrofula. As long as the appe- 
tite and general health remain good, and the local affections have not 
occurred, the composition of this fluid is, so far as known, unaltered. In 
the cachexia which is present when the general health is impaired, the 
blood becomes impoverished, the red corpuscles lose a portion of their 
coloring matter, and the watery element predominates. 

Does the glandular hyperplasia of scrofula produce an excess of the 
white corpuscles? Virchow says [Cellular Pathology, Lect. IX.): 
" During the progress of an attack of scrofula, in which, if the disease 
run a somewhat unfavorable course, the glands are destroyed by ulcera- 
tion, or cheesy thickening, calcification, etc., an increased introduction of 
corpuscles into the blood can only take place as long as the irritated gland 
is still, in some degree, capable of performing its functions, or still con- 
tinues to exist ; as soon, however, as the glands are withered or 
destroyed, the formation of lymph-cells likewise ceases, and with it the 
leucocytosis. In all cases, on the other hand, in which a more acute 



ANATOMICAL CHARACTERS. 125 

form of disturbance prevails, connected with inflammatory tumefaction of 
the gland, an increase of the colorless corpuscles always takes place in the 
blood." Although the glandular hyperplasia occurring in scrofula in- 
creases the number of white corpuscles in the blood, scrofula cannot be 
regarded as sustaining any causative relation to that great and constant in- 
crease of white corpuscles which characterizes the disease leucaemia ; for 
this disease, as remarked by Niemeyer, does not occur in childhood, 
when the scrofulous diathesis is active, but in manhood, when it has 
ceased to exist, or has become latent. 

Strumous inflammations of the cutaneous and mucous surfaces, which 
we have seen are the initial lesions in a large proportion of scrofulous 
cases, do not present any peculiar anatomical characters. Some of them 
are attended by an abundant formation of cells, and by dense infiltration 
of the inflamed tissues ; but inflammations which do not depend on the 
strumous diathesis may present these same characters. The most marked 
differences between the strumous and non-strumous inflammations are 
found in their origin, amount of cell-formation, and duration. 

The swelling of the lymphatic glands, which is so common in the 
neighborhood of scrofulous ailments, and which we have seen is in most 
instances the result of " conducted irritation," is due to hyperplasia of 
the lymphatic glands, with comparatively little or no increase of the 
stroma. Thus hyperplasia of the cervical glands is common, resulting 
from eczema of the scalp or face, or from otitis, or any of the forms of 
stomatitis ; and so pharyngitis often gives rise to hyperplasia of the ton- 
sils, which are lymphatic glands. The scrofulous nature of the glandular 
enlargement is apparent from the fact that it continues long after the pri- 
mary inflammation which gave rise to it has abated. Lymphatic glands 
sometimes enlarge in those who are not scrofulous, either from direct in- 
jury or propagated inflammation, but the tumefaction is commonly less in 
degree, and in most instances it soon abates when the exciting cause is 
removed. 

The glands which most commonly undergo scrofulous enlargement are 
the cervical, inguinal, bronchial, and mesenteric ; but in those who are 
decidedly scrofulous, the glands in the vicinity of any protracted inflam- 
mation are very prone to hyperplasia. Thus I have seen enlarged and 
cheesy glands in the vicinity of scrofulous ostitis, or periostitis. 

Under favorable circumstances the glandular enlargement abates after a 
short time, by absorption of the redundant cells. But the products of 
hyperplastic or inflammatory action in the scrofulous individual are very 
apt to undergo cheesy degeneration, and the close causative relation of 
this cheesy substance with tubercles is now admitted. If resolution do 
not soon occur in the gland, it begins to undergo cheesy degeneration. It 
becomes firm and inelastic, its nutrient vessels narrowed and compressed, 
so that circulation through it ceases, and its cells, losing their liquid and 



126 SCKOFULA. 

vitality, shrivel away. This necrobiotic process appears in points in the 
gland, which enlarge and unite, till finally the whole gland becomes a 
dead mass, with shriveled elements, of a whitish appearance, like cheese, 
the resemblance to which has suggested the name by which the degen- 
eration is known. 

In certain patients cheesy glands act as an irritant, like inorganic 
matter, producing suppurative inflammation, and their history thenceforth 
is that of an abscess. Purulent matter mixed with the cheesy debris 
escapes by ulceration upon the nearest surface, and scrofulous ulcers re- 
sult, which slowly heal, leaving permanent cicatrices ; calcification of 
a cheesy gland occurs in exceptional instances. 

The cervical lymphatic glands, having undergone hyperplasia in the 
scrofulous child, not infrequently continue painless and indolent for a con- 
siderable time, producing, according to their size, an unsightly appearance, 
and without undergoing cheesy degeneration. Finally one or more be- 
comes inflamed, and the broken-down gland substance softens and is 
expelled, mixed with pus, through an ulcerated opening in the skin. 

In order to complete the description of the anatomical character of 
scrofula, it would be necessary to describe the various inflammations to 
which the diathesis gives rise. Those which are most common and im- 
portant occur in the skin, mucous membrane, connective tissue, the 
joints, the bones with their periosteal covering, and the eye and ear * 
eczema and coryza are very common scrofulous ailments. Phlyctenular 
keratitis with great intolerance of light, otitis externa, causing protracted 
otorrhcea, or media and interna, causing deep-seated pain, with impair- 
ment or loss of hearing, offensive purulent discharge, and, in the gravest 
cases, caries of the mastoid cells or caries extending along the petrous por- 
tion of the temporal bone even to the brain, causing meningitis and death, 
are not uncommon manifestations of scrofula, in the families of the city, 
poor. Strumous cellulitis, occurring independently of the glandular affec- 
tion, and quickly ending in suppuration, is also common. The term cold 
is applied to the abscess when the local symptoms are slight, and there is 
but little heat of the parts. In young children the common seat of these 
abscesses is directly under the skin, so that if subcutaneous cellulitis run- 
ning into an abscess occur in a young child, he probably has the strumous 
diathesis. 

The osseous system is also very prone to inflammation in the scrofu- 
lous. Periostitis, ostitis, and arthritis, rare in those with healthy consti- 
tutions, are common in the scrofulous, in whom they result, even from 
very slight injuries, and sometimes without the recollection of any injury, 
and apparently from the direct influence of the diathesis. These inflam- 
mations are more common in the lower extremities than in the upper. 
Periostitis often occurs in scrofulous children without ostitis, when 
its usual seat is upon the shafts of the long bones, and it also accompanies 



SYMPTOMS. 



127 



inflammation of the bone, as pleurisy accompanies pneumonia. The 
osseous inflammations of strumous patients are of two kinds : first, the 
destructive, producing caries with suppuration, or necrosis ; and, secondly, 
the so-called fungous, in which there is proliferation of tissue as in white 
swelling. Often both these processes co-exist, granulations and new tissue 
springing up, while the carious or necrotic process is extending. 

Dactylitis is in most instances, when occurring in young infants, a syph- 
ilitic affection, but in children of one year or more, in whom no marked 
syphilitic symptoms have previously occurred, it originates from the stru- 
mous cachexia, as in the following case : Charles R., aged twenty 
months, was admitted into the Fig. {). 

New York Infant Asylum in 1876. 
He had always been pallid, and had 
a strumous aspect. A physician 
acquainted with his parentage states 
positively that he is free from 
syphilitic taint, but when a few 
months old he had a mild form 
of coryza, which gradually abated 
under anti-strumous treatment. At 
the age of five months he had 
purpura lnemorrhagica of a severe 
form, but apparently not accom- 
panied by haemorrhage from any of 
the mucous surfaces. The patches 
of extravasated blood were quite 
numerous and large over the trunk 
and limbs, and it was nearly three 
months before they entirely dis- 
appeared. A few months subse- 
quently he began to have offensive otorrhea on one side, which did not 
entirely cease. In December, 1870, at the age of eighteen months, well- 
marked dactylitis was first observed, involving the first phalanx of the 
left middle finger. The swelling was somewhat tender, and the skin 
which covered it had a slightly reddish or pinkish tinge, indicating the 
inflammatory nature of the malady. Neither joint at the extremity of 
the phalanx was involved, so that the movements were unimpaired. The 
dactylitis increased somewhat after it was first discovered, and then began 
to decline, under treatment with the cod-liver oil and syrup of iodide of 
iron. The accompanying wood-cut represents the outlines, obtained by 
tracing the hand of the infant, when pressed on paper. 

Symptoms. — The scrofulous diathesis is exhibited by certain physical 
sigus, which are present in infancy, but are more manifest in childhood. 
In one class of strumous children they are as follows : form, tall and 




128 SCROFULA. 

slender ; quickness of movement and perception : intelligence, good ; 
skin, thin and semi-transparent, through which the superficial veins are 
distinctly seen: features, delicate; cheeks, habitually pallid or florid, and 
flushed by slight excitement ; eyes, bright, with bluish conjunctiva ; 
muscles and bones, slender in proportion to their length. Those children 
who present these peculiarities are said to have the erethitic form of the 
diathesis. 

Others have what has been designated the torpid scrofulous habit, 
which is characterized by softness and flabbiness of the flesh, distended 
abdomen, large head, broad face, slow, languid movements, and an over- 
production of fat in the subcutaneous connective tissue in certain situa- 
tions, especially the nose and upper lip. Though typical cases can be 
readily referred to one or the other of these forms, there are many 
which are intermediate. 

One of the earliest of the scrofulous manifestations is subcutaneous cel- 
lulitis, alluded to above, giving rise to abscesses, commonly not large, 
with little surrounding induration, little pain, tenderness, and heat, and 
slow in discharging ; in a word, indolent. The most frequent seat of 
these abscesses is upon the extremities, but they may occur upon the scalp 
or elsewhere. They gradually heal when the pus escapes, their site being 
indicated for a considerable time by the depression and reddish discolora- 
tion of the skin, which gradually returns to its normal state. Ordinarily, 
these abscesses do no harm apart from the reduction of the general health 
which they effect, but, when occurring in localities where the connective 
tissue lies upon the periosteum, as upon the Angers, periostitis may result, 
with destruction of the surface of the bone. Again, thrombi may occur 
in the vessels of the inflamed part, giving rise to emboli, embolismal pneu- 
monia, and death. Specimens from such a case were presented by me to 
the Xew York Pathological Society in 1868. 

The scrofulous affections of the skin often also occur at an early age-, 
even before dentition. They are more frequent in infancy than in child- 
hood. The most common are eczema and impetigo, and of rare occur- 
rence, ecthyma and lupus. But all these may occur in those who are 
not strumous or who do not present the characteristics of the strumous 
diathesis. 

Scrofulous affections of the mucous surfaces are scarcely less frequent 
than those of the skin. They present the ordinary features of mucous 
inflammations of a subacute and chronic character. 

Sometimes they occur without obvious exciting cause ; iu ether cases 
there is a cause of this kind, such as exposure to cold ; but the inflam- 
mation, once established, continues on account of the diathesis. It is often 
doubtful whether inflammations in strumous subjects be of such a char- 
acter that it is proper to designate them strumous, especially if they occur 
upon such surfaces as are frequently the seat of ordinary inflammation. If the 



SYMPTOMS. 129 

child have heretofore presented symptoms of scrofula, if the inflammation 
be subacute, and there be no apparent cause to originate or sustain it apart 
from the diathesis, it is probably of a strumous character. The diagnosis 
is rendered more certain by observing the effect of anti-strumous reme- 
dies. The most frequent of these scrofulous inflammations of mucous 
surfaces are coryza, tracheo-bronchitis, and conjunctivitis. More rarely, 
stomatitis, pharyngitis, vaginitis, and, according to some, entero-colitis, 
are of a strumous character. Coryza gives rise to snuffling respiration, 
the formation of crusts around and within the nares, and excoriation of 
the upper lip. The tracheobronchitis is attended by thickening of the 
mucous membrane, increased production of mucus and epithelial cells, 
and a loud tracheal rale, accompanying each inspiration. 

Strumous inflammation of the mucous membrane of the trachea and 
bronchial tubes is not a very infrequent disease in this city. It sometimes 
originates in a simple inflammation from cold, or the tracheo-bronchitis 
of measles, or pertussis, and it is apt to continue, with its rales, cough, 
and scanty expectoration, for months, unless relieved by a proper course 
of treatment. 

Among the most common of the strumous affections, are inflammation 
of the eyelid, designated psorophthalmia, and that of the eye itself. The 
former is characterized by redness and thickening of the lids, detachment 
of the eyelashes, and inflammation and altered secretion of the " Meibo- 
mian glands" ; the latter, namely, strumous ophthalmia, by pain, lachry- 
mation, photophobia, and a moderate degree of hypenemia of the affect- 
ed organ. One of the most common serious results of strumous inflam- 
mation affecting the eye, arises from the conjunctivitis and keratitis, 
namely, the formation of phlyctenular and ulcers on the margin of the 
conjunctiva and upon the cornea, fed by newly formed vessels. If not 
controlled by proper treatment, these may result in opacities more or less 
permanent, or possibly, worse still, in perforation, with its consequent ill 
effects. 

Inflammations of the external and middle ear have their origin very 
generally in the strumous diathesis. Occasionally there is an exciting 
cause of the otitis, as an injury, or severe constitutional disease, like scar- 
let fever. Protracted otitis, whether external or internal, and especially 
that form of it which leads to ulceration, destruction of the ossicles, and 
caries of the petrous portion of the temporal bone, it is proper, in a large 
proportion of cases, to regard and treat as strumous. 

I have stated that inflammations of the osseous system are common in 
strumous children. Some of the best observers and highest authorities, 
as regards the surgical diseases of children, both in this country and 
Europe, state that they do not consider these affections to be of a stru- 
mous nature ; while others regard them as manifestations of struma. After 
carefully examining the reasons for this variance in opinion, I am con- 



130 SCROFULA. 

vinced that the difference of views in reference to this matter occurs from 
a different understanding of the nature of scrofula. Those who state that 
the affections alluded to are not scrofulous, believe, so far as I have been 
able to ascertain, that scrofula and the tubercular diathesis are identical. 
As tubercles are not, as a rule, present in children who suffer from these 
affections, it is therefore held that these affections are not scrofulous. If 
those holding this belief were told, or could be made to believe, that scrof- 
ula is entirely distinct from the tubercular diathesis, that it is merely a 
name applied to a diathetic condition in which the tissues are easily 
wounded, there would probably be but one opinion as regards the scrofu- 
lous nature of these inflammations ; for I have often had an oppor- 
tunity to observe, they occur in a large proportion of cases from very 
trivial injuries, showing a highly vulnerable state of the tissues. 

Holmes, in his useful and eminently practical Treatise on the Surgical 
Diseases of Children, says of one of the most common of the affections 
alluded to, namely, morbus coxarius : " The affection in question occurs 
very frequently in strumous children, a circumstance which has led to its 
being denominated strumous. ... If by strumous be meant a state of 
the system which renders the subject of it prone to the deposit of tubercle 
in the viscera, I think that there is good reason for asserting that morbus 
coxarius often attacks children who are not strumous, i.e., who display no 
such tendency to the deposit of tubercle." Still, Mr. Holmes states 
' ' that there is that condition of the system which disposes its subjects to 
the development of low inflammations of various kinds," which is almost 
the full definition of scrofula, as understood by us. 

The stubbornness and frequent disastrous consequences of scrofulous 
inflammation of the skeleton are well known. Nearly every bone, as well 
as its periosteum, is liable to this form of inflammation, but some are 
more frequently affected than others. Inflammation of the bone may 
terminate by resolution, by the formation of an abscess, or, and frequent- 
ly, by carious or necrotic destruction of the bone itself. Necrosis is most 
apt to occur in the shafts of the long bones, caries in the spongy extrem- 
ities of these bones, and in the spongy portions of the short bones. If 
abscesses form, the pus may finally escape from the system by a tedious 
ulcerative process, or, retained, may undergo cheesy degeneration. Scrof- 
ulous arthritis, if early detected and properly treated, may resolve, leav- 
ing no ill effect ; if otherwise, suppuration, ulceration, cartilaginous and 
osseous, and anchylosis, are apt to result. 

Scrofulous children are perhaps no more liable to inflammation of the 
internal organs than other children, but the inflammatory products are 
more liable to cheesy degeneration, and the prognosis is therefore less 
favorable. The most frequent of these inflammations, and the one of 
chief interest, is pneumonia. Catarrhal pneumonia, so frequent in early 
life, whether primary or secondary, in connection with measles, pertussis, 



RELATION OF SCROFULOSIS TO TUBERCULOSIS. 131 

etc., is a disease often involving grave consequences in those who are de- 
cidedly scrofulous ; since, instead of resolving, the affected lung-tissue 
presents a strong tendency to caseous degeneration, ending in consump- 
tion of the lungs and death. I have most frequently noticed cheesy pneu- 
monia during extensive epidemics of measles, as a complication or sequel 
of this disease. It may occur in those who are not scrofulous, if the vital 
powers be greatly reduced, but it is so much more common in the scrof- 
ulous, that some recent writers have designated this form of inflamma- 
tion by the term of scrofulous, instead of cheesy, pneumonia. From the 
fact, however, of its sometimes occurring in the non-scrofulous, the term 
cheesy or caseous, especially, too, as it expresses the anatomical state, 
seems more appropriate. 

Relation of Scrofulosis to Tuberculosis. — Tuberculosis, in a large 
proportion of cases, results from the substance which is produced by case- 
ous degeneration. In a caseous mass when it softens, are found fat glob- 
ules, albuminous granules, and a large amount of matter in solution. 
These are reabsorbed to a greater or less extent, and in them is the sub- 
stance which, lodged in healthy tissue, causes the peculiar cell prolifera- 
tion, by which the tubercle is produced. The theory that this agent acts 
as an embolus intercepted in the capillaries, has its advocates. In many 
instances the intimate causative relation of the substance produced by 
caseous degeneration to the tubercular neoplasm appears from the fact 
that tubercles are developed in abundance in the cheesy focus, while there 
are no tubercles in other parts of the system. Fungous and ulcerative in- 
flammations occurring in the osseous system afford common examples. 
Now since cheesy matter in the system of a young person results, in 
most instances, from the products of those inflammations which we 
recognize as scrofulous, we see the intimate relation between scrofulosis 
and tuberculosis, and why for a long time the strumous and tubercular 
diatheses were considered identical. 

Prognosis. — As scrofula may be acquired through anti-hygienic influ- 
ences, so it may disappear or become latent through influences of an op- 
posite character. Therefore the manifestations of scrofula may be limited 
to a brief period, or they may occur at intervals through the whole of child- 
hood, and the first years of youth. When the diathesis is inherited, and 
fostered by unfavorable circumstances, the scrofulous affections appear 
earliest, are most varied and severe, and continue longest. 

In most cases, with proper treatment, the prognosis is good, but the 
danger to life depends on the nature and extent of the scrofulous inflam- 
mation. The most common unfavorable result is the occurrence of pul- 
monary or general tuberculosis from the infection supplied by the cheesy 
substance, in the manner stated above. This is the usual result from 
cheesy pneumonia. The next most common cause of death, either 
directlv or indirectlv, is inflammation of the osseous svstem. Many 



132 SCROFULA. 

deaths occur from inflammation of the vertebrae, or of the hip or knee 
joints, when it has been allowed to continue a considerable time without 
proper treatment. Protracted suppurative inflammation of the bones is 
apt to produce amyloid degeneration of organs, which is permanent, and 
likely to prove fatal, or death may occur from exhaustion, with or with- 
out tuberculosis. Among the city poor meningitis is not very uncommon, 
consequent on long-continued otitis media and caries of the petrous por- 
tion of the temporal bone. Permanent impairment of sight and hearing 
often results from neglected strumous ophthalmia and otitis. 

After the age of puberty the strumous affections cease, and among the 
most robust adults are those who in early life presented indubitable symp- 
toms of the strumous diathesis. 

Treatment. Prophylactic. — Measures designed to prevent scrofula 
are impossible without the co-operation of willing and intelligent parents. 
It is obvious that the prevention of congenital scrofula requires the treat- 
ment of disease or impaired health in the parent. If parents should be 
taught, or should remember, that good health in themselves is the neces- 
sary condition of the inheritance of a sound constitution in the child, and 
would adopt such therapeutic and regimenal measures as would procure 
this, the number of cases of inherited scrofula would be materially re- 
duced. 

As the first years of life are very important, both for correcting the 
diathesis when inherited, and for preventing its development in those of 
sound constitution, care should be taken that the regimen of the child be 
such as would in no way produce deterioration of the general health. The 
nursing infant, if the mother be in poor health, should be provided with a 
healthy wet-nurse, for in young children the diathesis may be acquired 
solely by the use of food that is scanty or of poor quality. Those old 
enough to be weaned should have plain and nutritious diet, with a proper 
admixture of animal food. More or less outdoor exercise, and residence 
in a salubrious locality, with sufficient air and sunlight, are requisite. 

Curative. — As scrofula originates in a state of weakness existing in the 
parent in the congenital, and in the child in the acquired form of the dis- 
ease, and is characterized by feeble resistance of the tissues to irritating 
agents, the inference is reasonable that all tonics have, to a certain extent, 
an anti- scrofulous effect upon the system. The ordinary vegetable tonics, 
and sometimes the ferruginous, are indeed useful in the treatment of scrof- 
ula. Employed in connection with proper regimenal measures they are 
sufficient, in manv cases, to remove the diathesis after a time, or render 
it latent. Besides these medicinal agents, which tend to correct the scrof- 
ulous diathesis by their general tonic effect, there are certain others which 
experience has shown to be beneficial in the treatment of scrofulous affec- 
tions, and which are, therefore, largely used. One of these is cod-liver 
oil, which contains iodine, with numerous other ingredients. 



TREATMENT. 133 

Cod-liver oil is useless or nearly so in the torpid form of the diathesis, 
which is characterized by an increased deposit of fat in the subcutaneous 
connective tissue, slow circulation, and sluggish muscular movements. 
On the other hand, in the treatment of the erethitic form it possesses real 
value. Its protracted use in such cases does so modify the molecular con- 
dition of the tissues that they are less liable to inflammation, and the dia- 
thesis is, therefore, rendered milder or removed. From one to three tea- 
spoonfuls, according to the age, should be given three times daily. While 
we frequently experience so much difficulty in administering it to adults 
affected with tuberculosis, and sometimes find it necessary to discontinue 
its use on account of its nauseating effect, scrofulous children rarely refuse 
to take it, and it does not seem to diminish their appetite. 

Iodine is justly celebrated as a remedy in the treatment of scrofulous 
maladies, but it is a question whether it has not been overrated as a 
remedy for the diathesis itself. Iodine employed internally is especially 
serviceable in glandular hyperplasia, and in scrofulous thickening and in- 
duration of the connective tissue and periosteum. In general, it should 
not be administered to children in its isolated state, on account of its 
irritating properties, but one of its compounds should be employed. The 
compounds which are chiefly prescribed in the treatment of scrofula are 
the iodides of starch, iron, potassium, and sodium. If, as is frequently 
the case, the patient be pallid, and his appetite poor, the iodide of iron 
should be preferred ; if not in this cachectic state, the iodide of starch. 
Pharmaceutists prepare syrups of both these iodides, so that they can be 
readily administered to the youngest child. The iodide of starch may be 
administered by dropping from one to five drops of the officinal tincture 
of iodine on a little powdered starch, and giving it in syrup. These io- 
dides are preferable to the iodides of potassium and sodium for internal 
administration to children, as they are not irritating to the mucous mem- 
brane, and the iodine is readily set free. Prof. Dalton has, indeed, de- 
monstrated that the iodide of starch is decomposed in most of the liquids 
of the body, and the iodine liberated. 

In New York city a large proportion of the scrofulous children are 
cachectic, and need iron, and the iodide of iron is more frequently em- 
ployed, and with good results, than any other iodine compound. The 
syrup of the iodide of iron, which is readily absorbed, should be given in 
one to two-drop doses three times daily to a child of six months, and one 
additional drop added for each additional year. Among the vaunted 
remedies of scrofula are phosphoric acid and the phosphate of lime. I 
have not employed these agents without at the same time using other 
remedies, and cannot say, therefore, to what extent they have been cura- 
tive in my practice. Probably there is no better combination of remedies 
for the strumous diathesis than the following, which is now used in some 
of the institutions of New York : 



134 SCROFULA. 

IJ. 01. morrliuse, 2 parts ; 

Syr. calcis lactophosphat., 1 part. Misce. 

Dose, one teaspoonful to a dessertspoonful three or four times daily, to 
eacli dose of which, the syrup of the iodide of iron may be added at the 
time of its employment. 

The internal use of mercury as an antidote for scrofula is now generally 
discarded. Unless, perhaps, in those cases in which the diathesis is im- 
mediately dependent on syphilis, its use for this purpose, from what we 
know of its therapeutic effects, would probably be more injurious than 
beneficial. Among the medicines which have from time to time been em- 
ployed for the cure of scrofula, some of which have had considerable repu- 
tation but have nearly fallen into disuse, are walnut leaves, sarsaparilla, 
elecampane, conium, digitalis, horseradish, compounds of silver, gold, 
arsenic, baryta, and bromine. It is probable that none of these has any 
effect on scrofula or scrofulous ailments, except such as improve the appe- 
tite and general health, as horseradish. 

• The same hygienic measures are required in the treatment of scrofula 
as are demanded in the prophylaxis of it. The nursing infant should 
have healthy breast milk, and if its mother belong to a tubercular or scrof- 
ulous family, or be feeble, a healthy wet-nurse should be employed, or it 
should be sent to the country, where suitable cow's milk can be obtained. 
In the city, the infant may be fed during the cool months with porridge 
made of the best cow r 's milk and barley flour, rice flour, Ridge's or Nes- 
tle's food, or one of the preparations of Liebig's soup ; but, as stated else- 
where, such food will prove disastrous to infants under the age of twelve 
months who are kept in the city during the hot term. Their removal to 
the country is indispensable, both as regards the treatment of struma, and 
to prevent intestinal catarrh. The expressed juice of beef slightly boiled, 
given several times daily in small quantity to infants, aids materially in re- 
storing a better nutrition of the tissues. Obviously similar care is neces- 
sary in the selection and preparation of the food of children who have 
passed beyond the period of infancy. While the diet should be highly 
nutritious, it should be plain, and easily digested, and given at sufficient 
intervals, so as not to overtax digestion. 

Fresh air, out-door exercise, daily bathing, personal and domiciliary 
cleanliness, are very necessary for the most successful treatment of the 
diathesis. Since scrofula is comparatively infrequent in farming sections, 
scrofulous families are greatly benefited by farm life, with all the accesso- 
ries to health which pertain to it. 

The local scrofulous ailments require additional and special treatment. 
Those located on the cutaneous and mucous surfaces are less dangerous, 
as a rule, than the deeper seated inflammations ; still they should be 
promptly treated, not only for the inconvenience and annoyance which 



TREATMENT. 135 

they cause, but because they are apt to lead to hyperplasia of the neigh- 
boring glands, which sometimes proves serious. Thus a pharyngitis may 
cause a peripharyngeal adenitis and abscess, and a bronchitis may cause 
an adenitis of the bronchial glands, with the probability of their cheesy 
deo-eneration. The so-called bronchial phthisis is believed to result, in a 
large proportion of cases, from a strumous bronchitis, which has been 
allowed to run on uncontrolled by medicine, and a similar state of the 
mesenteric glands may result from intestinal catarrh in the strumous. In- 
flammations of the skin and mucous surface occurring in the strumous, re- 
quire the continued use of anti-strumous remedies, conjoined with such 
treatment, designed to act locally, as is appropriate for individuals who are 
not strumous. 

It is the common practice to treat the enlarged glands of struma by 
daily applications over them of the stronger iodine preparations. This 
treatment does not cause absorption of the redundant gland substance. It 
causes proliferation of the epidermic cells, and quickens the cell change 
in the gland underneath so that leucocytes are apt to form in it. Cutane- 
ous inflammation, as eczema or impetigo, causes hyperplasia of the lymph- 
atic glands underneath. In like manner strong applications, which irri- 
tate the skin, are apt to quicken the cell formation, so that suppuration is 
a common result. I once produced accidentally such an amount of vesi- 
cation over an enlarged, hard, and apparently indolent gland in an infant 
of fourteen months, that I was very anxious lest a sore would result, 
which would heal with difficulty, and yet instead of dispersion of the 
glandular swelling the pathological processes were so promoted that sup- 
puration and discharge of pus occurred by the time that the cuticle had 
reformed. 

We know no better substance for the local treatment of strumous ade- 
nitis than iodine, and it should be applied, in my opinion, in such a man- 
ner that it is absorbed with the least possible irritation of the gland. The 
following will be found useful ointments and solutions for the treatment 
of these cases : 

3 . Potas. iodidi, 3 j , 
Ung. stramonii, 3J. 

To be rubbed over the gland several times daily. It should not be ap- 
plied as a plaster, as it is too irritating and will vesicate. I have known 
a glandular swelling, which had continued about three months, to disap- 
pear in three weeks under its use in connection with internal remedies. 
Vaseline, in place of the stramonium ointment, makes a nicer preparation. 

3 . Liq. iodinii composita, 
Glycerina?, equal parts. 

To be applied as an inunction. Glycerine renders the skin soft and in a 
state favorable for absorption. 



136 SCROFULA. 

In The Medical Press and Circular for August 3d, 1870, J. Warino- 
Curran states that he has used with great success what he designates a 
new iodine paint, consisting of half an ounce of iodine, the same quantity 
of iodide of ammonium, twenty ounces of rectified spirits, and four 
ounces of glycerine. 

Mercurial ointments have been recommended by writers of reputation 
for the treatment of these glands. I have employed them, and known 
them to be employed, but cannot say that I have ever observed any bene- 
fit whatever from their use. In the children's class at the Out-door De- 
partment at Bellevue we have discarded them entirely for this purpose, 
although both the citrine and white precipitate ointments, diluted with an 
equal quantity of lard, have been used with apparent benefit for chronic 
coryza of a strumous nature, and also occasionally for external otitis of 
the same nature. 

In a paper read at the meeting of the British Medical Association in 
1870, by Mr. Jordan, the writer recommends, as attended with success, 
vesication, not over the gland, but at a little distance from it, as, for ex- 
ample, behind the neck, for treatment of the cervical glands. But a 
mode of treatment which seems so unlikely to be beneficial requires 
stronger proof of its utility than has yet been presented. 

When the gland becomes actively inflamed, as indicated by increased 
heat and tenderness, and redness of the skin, applications of iodine are no 
longer proper. They increase the local disease. There is no longer any 
probability of resolution of the glands, and poultices should be applied. 

In strumous conjunctivitis and keratitis, solution of sulphate of 
atropia, two grains to the ounce of water, should be dropped three times 
daily into the eye. It relieves the photophobia, while it exerts a curative 
effect on the inflammation. To remove the phlyctenula and opacities, 
finely powdered calomel should be dusted into the eye (see remarks by 
Dr. Pomeroy in the following article). For the otitis, injections of tepid 
water to which a little carbolic acid is added (gr. ij to iij to the ounce) 
should be employed, and afterward a mild astringent. 

It is important that the diseases of the osseous system should receive 
early treatment, but, unfortunately, it is in reference to these inflammations 
that error of diagnosis is frequently made. Thus I have known periostitis, 
with the diffused redness of the skin and heat which it produces, to be 
mistaken for erysipelas, until the diagnosis was corrected from its persist- 
ence and non-extension. It is remarkable that strumous arthritis some- 
times appears in two or more joints at once, as in the case related below. 
I have known it to occur nearly simultaneously in three joints, though only 
for a brief time in two of the joints, while it was chronic in the other. 
Hence, the fact that this inflammation is often mistaken for inflammatory 
rheumatism, and treated as such for some days, tillits nature becomes ap- 
parent ; and in like manner the febrile movement, lassitude, abdominal 



STRUMOUS DISEASE OF THE JOINTS 



137 



Fig 



pain, etc. , of vertebral caries are, in a large proportion of cases, attributed 
to something else, and the true disease not suspected till irreparable dam- 
age has occurred, or much longer confinement and treatment required 
than would have been necessary with an earlier diagnosis. 

The common strumous inflammations of the osseous system which in- 
volve the joints, as Pott's disease, hip-disease, and white swelling, are 
usually quite amenable to treatment, early applied, 
which insures complete rest ; but, as a rule, cases 
neglected, or wrongly treated, go from bad to 
worse. There are exceptions, for a case may do 
well or terminate with moderate deformity without 
treatment, as in the following interesting instance, 
which also shows the difficulty which often attends 
diagnosis : 

Anna D., aged six years, came to the children's 
class in the Out- door Department at Bellevue in 
February, 1877, with the following history : Her 
health was good till two years ago, when she com- 
plained of pain of a mild form in both knees. Her 
parents attributed it to her rapid growth, and she 
was always able to walk with little suffering. Slowly 
but steadily these joints began to swell. She has 
had no pain in other joints, and no member of the 
family has had rheumatism except a grandparent. 
She walks without complaint to the rooms of the 
Bureau. The affected joints are about equally 
swollen, and it is evident on examination that they 
contain some serous effusion. Direct pressure is 
not painful, but pressing the bones together with a twisting or rotating 
movement gives some pain. She is pale, and has a strumous aspect. A 
sister of fifteen years has a similar swelling of one knee, which began at 
the age of seven or eight years, but which has received no regular treat- 
ment, has not prevented the free use of the limb, and has given her little 
inconvenience. 

The physicians who have examined this child, one of whom is an ex- 
pert in orthopaedic surgery, agree that the disease is strumous and not 
rheumatic, and that it did not, during two years of neglect and unrestrained 
motion, go on to suppuration and destruction of the joints, was probably 
due to her good general health. 

Though the result in the above case was good, since there was little im- 
pairment in the use of the joints, and no suffering, yet delay and neglect 
in the treatment of all those strumous inflammations which involve the 
joints are exceedingly dangerous, for if left to themselves they most fre- 
quently end in suppurative inflammation and ulceration, with all the sad 




138 STRUMOUS OPHTHALMIA. 

consequences which these entail. Strumous inflammations of the osseous 
system now receive more early and correct treatment than formerly, and 
orthopaedia, almost unknown till within the last twenty years, has become 
an important branch of surgery. Formerly in New York, especially in 
the tenement houses, we often met emaciated bed-ridden children with 
strumous osteitis and arthritis, their limbs swollen, and painful in motion, 
and offensive from the discharge, for the most part shunned by physi- 
cians, and with no prospect of relief except by amputation. Now this 
spectacle is comparatively infrequent. The early symptoms of these 
diseases being better understood and sooner recognized, the plaster of 
Paris or starch dressing to insure immobility, or ingeniously devised steel 
splints, which produce extension, and allow motion of the limb without 
friction of the inflamed surfaces, coming into general use, a large propor- 
tion of cases do not go beyond the first stage and are cured. 

Strumous Ophthalmia. 

{Written by Dr. 0. D. Pomeroy, Surgeon to the Manhattan Eye and Ear Hospital.) 

Strumous ophthalmia in young children, as described by the older writ- 
ers, is simply a keratitis, or inflammation of the cornea, and is usually of the 
following varieties : phlyctenular or herpetic keratitis, and diffuse or 
parenchymatous keratitis. Perhaps it is a misnomer to designate these 
affections strumous. This general principle governs most cases of these 
inflammations, to wit, depressed vital energy, which of course is the promi- 
nent characteristic of the strumous diathesis. As is well known, the 
cornea is a tissue of low vital power, and any constitutional state, 
accompanied by depression, predisposes to an attack of keratitis. One of 
the commonest hospital experiences is to see a mild case of catarrhal 
conjunctivitis, which should be self -limiting, gradually extend to the 
cornea, causing an ulcerative keratitis. I believe all ophthalmic surgeons 
hold that the presence of corneal disease, not dependent on an obvious or 
specific cause, points to diminished vitality on the part of the patient. 

Herpetic or phlyctenular keratitis is the most frequent variety of cor- 
neal disease in children. It is a question whether it commences with a 
vesicle on the cornea, or a papule ; but in either case it soon becomes an 
ulcer. Ciliary injection probably precedes it, though this can by no 
means be always observed. In some patients the characteristic symptom, 
to wit, photophobia, may exist for a long time without injection of the 
eyeball, or any corneal changes whatever, but sooner or later it is proba- 
ble that other characteristic signs of the disease will make their appear- 
ance. The photophobia is frequently accompanied by blepharospasm, 
making it well nigh impossible to separate the eyelids. When, however, 
this is accomplished, abundant tears gush forth, the child exhibiting signs 
of extreme distress. When the vesicle or papule is in a state of ulcera- 



PHLYCTENULAR KERATITIS. 139 

tion in the earlier stage, there may only be seen a minute loss of corneal 
tissue, without any opacity whatever. Soon, however, the ulcer becomes 
more or less opaque, perhaps seeming to be only a minute whitish spot on 
the cornea. This usually shows the commencement of reparative action. 
If the disease continue long a general conjunctivitis sets in, more 
especially of the ocular conjunctiva. Frequently there will be only one 
or not more than two or three ulcers, but, in exceptional cases, the cornea 
may have the periphery studded with phlyctenule, which, instead of 
promptly healing, proliferate so as to form elevated nodules, the so-called 
" scrofulous nodular bands." If the ulcer in any case continue long, a 
number of bloodvessels shoot out from the conjunctival border of the 
cornea, quite up to the ulcer, producing what may be termed a vascular 
keratitis. The discharge from the eye is often very acrid, causing 
catarrh of the lachrymal ducts, and even of the nares. Herpetic or 
eczematous eruptions on the cheeks, or the lip near the nostrils, are often 
seen, and may sometimes appear to be the cause of the disease rather 
than the effect. In this condition the upper lip may swell considerably, 
giving the patient a very " strumous" look. 

The duration of phlyctenular keratitis is exceedingly variable ; two 
or three weeks may bring it to a close, or it may continue many months. 
The condition of the constitution probably determines its duration as 
much as any other, factor. Of course if an ulcer perforate the cornea 
staphyloma may result, rendering recovery more tedious and incomplete. 
The diagnosis of this malady is not difficult. The photophobia, so charac- 
teristic of keratitis, is present in no other disease except iritis, and the lat- 
ter children rarely have ; the little speck, spot, or abrasion on the cornea, 
together with the intolerance of light, is well nigh diagnostic. Photo- 
phobia is present in most forms of corneal disease, though not in all. The 
causes of phlyctenular keratitis are about as follows : Any condition of 
the system known as strumous, or whatever tends to lower the vital pow- 
ers of the patient, affords a predisposing cause. I am impressed with the 
idea that exposure to cold or sudden change of temperature is the com- 
mon exciting cause, barring any cutaneous diseases which may pass 
from the skin to the eye. Naturally any cause which produces a con- 
junctivitis ma}'- also produce this disease secondarily. The process of 
dentition may have something to do with the eye disturbance, or any dis- 
order of the intestinal canal ; the latter, however, being rather predispos- 
ing than exciting causes. This disease also frequently occurs in patients 
affected with aural or nasal catarrh, but the condition of such children 
trenches closely on the state designated " strumous." 

The jn'oynosis in a large number of cases is very favorable. The 
opacities of the cornea left after the healing of the ulcerations are the 
principal difficulties in the way of a good recovery. If the opacities are in 
the proper substance of the cornea, we are not certain that they will dis- 



140 STRUMOUS OPHTHALMIA. 

appear by absorption, though they may. Nothing is more difficult than 
to determine this point. In the epithelial and Bowman's layers, as well as 
the posterior layer, opacities readily disappear. When the ulcer perforates 
the cornea w r e have an anterior synechia and the appearance known 
as myocephalon, which usually disfigures the eye more or less for life. 

One discouraging point about these opacities is that, though they disap- 
pear, the cornea is left with a somewhat distorted curvature, causing irreg- 
ular astigmatism, and if they chance to be near the centre of the cornea, 
great disturbance to vision results. I have often, in fitting spectacles, 
noticed that the patient's vision showed an unaccountable lowering, and on 
investigation have found a history of an infantile keratitis which had done 
all the mischief. In those cases described as having " scrofulous nodular 
bands, ' ' the proliferative nodules are very likely to undergo a variety of 
degenerations which do not end in a properly restored cornea. One 
great difficulty in making an exact statement here is the tendency of the 
keratitis to recur, and there is no knowing where the process will cease, 
after a number of recurrences. 

Treatment. — As the fifth nerve presides over the ciliary vaso-motory 
system of the corneal nutritive supply, it is obvious that treatment calcu- 
lated to correct any of its morbid manifestations would be rational. Such 
is found to be the fact. Sulphate of atropia, in from one to two grain 
solutions, dropped into the eye three times daily, is probably superior 
to any other treatment. It inclines to break up the orbicular spasms, 
relieving the photophobia and ciliary neuralgia, diminishes vascularity, 
and contributes more to the relief of the patient than any other one 
remedy. If the pain be severe the atropine may be used six or eight 
times daily, or even it may be instilled every fifteen or twenty minutes, 
until pain is relieved. If an over-effect be reached the patient complains 
of dryness in the throat, possibly pain in the head, or he may have other 
cerebral disturbances, when the drops may be discontinued for a time. 
Muriate of pilocarpine in two grain solutions may be used in a similar 
manner and for the same purpose ; but it contracts the pupil and renders 
the accommodation tense, the very opposite to the atropine effect. I 
have not much confidence in this remedy. Powdered calomel may be 
dusted into the eye every second day. A small quantity only should 
be used, since it is apt to collect in masses, which act as foreign bodies 
(we desire to produce irritation for a few minutes only). A drachm of 
table salt to a pint of water may be used to bathe the eyes freely four 
or five times a day, used warm or cold according to the patient's 
pleasure, though warm applications are more likely to be well received. 
Red precipitate ointment — 1J. (Vaseline, 3j; hyd. ox. rub. in very 
fine powder, gr. j to ij. M.) — placed under the eyelids everyday or two, 
is often very beneficial. Occasionally the ulcers show a disinclination to 
heal, when they may be touched with Arg. nit., gr. x., Aquas dist., f j. M. 



TREATMENT. 141 

Wind a bit of absorbent cotton on a probe, dip this into the solution, and 
touch the ulcer, but no other point. Cupri sulph., in ten grain solu- 
tions, may be used for the same purpose. A protective bandage exerting 
moderate pressure on the eye sometimes does good, but it should not feel 
uncomfortable. If there be much spasm of the orbicularis, however, it is 
not indicated. If the pain in the eye continue, and the orbicularis be in a 
state of spasm, a cantholysis may be done — that is, divide the external can- 
thus so as to cause the lid to no longer press hardly upon the eyeball, and 
close the wound thus made by stitching the skin to the conjunctiva above 
and below the incision, and placing one stitch in the extreme outer canthus. 
This extends the length of the palpebral opening. The result of the oper- 
ation is to temporarily break the power of the orbicularis, so as to 
arrest the spasm. This measure accomplishes in some cases what nothing 
else will. 

If the eye be painful, without spasm of the lid, and there be great 
photophobia, whether the eyeball be too hard or not, paracentesis 
may be done. The mode of performance is described in the treatment 
of ophthalmia neonati in another place in this book. After a while 
the accompanying conjunctivitis may need treatment in the ordinary 
way. Indeed astringents may often be used quite early to obviate the 
irritating effects which occasionally result from the use of atropine. If 
an ulcer refuse to heal after the treatment already laid down, iridectomy 
may be done, though this is not often resorted to. Occasionally an 
ulcer may be cut across, by passing a narrow Graefe's knife through 
it, making a puncture on one side and a counter puncture on the oppo- 
site side, and then cutting out quite through the ulcer, dividing it into 
two equal halves. All needful treatment for the constitutional condi- 
tion of the patient should be attended to. So necessary is fresh air and 
sunlight that I would never shut the patient in a dark room. Blue or 
smoke colored glasses may be worn to protect the eyes from a strong 
light, and in some cases the eyes may be protected by a bandage of 
some dark material, so that the patient may be taken for an airing with- 
out suffering. I would, however, advise to accustom the eyes to the 
light as much as possible without causing pain. A perforated cornea 
may require iridectomy. 

In parenchymatous or diffuse keratitis wc have quite a different array 
of symptoms. The margin of the cornea near the limbus may show a 
decided zone of injection of the conjunctival and episcleral vessels. It 
may be so excessive as to apparently consist of a rosy ring surrounding the 
cornea. These vessels after a time shoot inward, and may involve a large 
part, or even the whole of the cornea. In other cases, designated non- 
vascular diffuse keratitis, the injection is very slight indeed, and sometimes 
apparantly wanting altogether. In either case, however, the same conse- 
quences result ; the cornea becomes diffusely clouded, the process gen- 



142 STRUMOUS OPHTHALMIA. 

erally, but not always, commencing at the limbus. This cloudiness may 
be quite without lines or dots of opacity, like ground glass. Again it 
may appear composed of innumerable minute opaque points or lines run- 
ning in various directions. At first, the corneal epithelium escapes, pre- 
senting a regular and uniform polish, but afterward it becomes opaque. 
Again if the process involve the whole of the cornea, minute opaque spots 
may be seen in Descemet's membrane, giving it some of the characteristics 
of keratitis punctata. In the earlier stages there may be some pain and 
intolerance of light, but as a rule the disease, for a corneal affection, is com- 
paratively painless. The duration of this disease is never short ; it may 
continue for many months, and it shows a strong tendency to relapse. 
The most frequent causes are hereditary syphilis and struma. Mr. 
Hutchinson of London always examines the teeth of these patients to see 
if there be anything characteristic of hereditary syphilis. As the same or 
similar teeth are often noticed in strongly strumous subjects it becomes 
doubly interesting to make the observation. One point is apparent in most 
of these cases, that there are in almost every patient some signs of badly 
developed physique, that is, faulty tissue elaboration. As a rule both 
eyes sooner or later become affected, pointing to a constitutional origin of 
the affection. 

In treatment we are often disappointed in our efforts. At the first, if 
there be pain or photophobia, atropine may be instilled, and the eyes 
bathed with warm or tepid water, several times a day. Tonics or altera- 
tives are always indicated. One of the most useful prescriptions is the 
following : 

5> • Hydrarg. Chlor. corros. , gr. j ; 

Tine. Cinclion comp. , 

Syr. Aurantii, aa, 0v. Misce. 
Dose. — One teaspoonful three times daily after eating. 

Iodide of potassium is frequently given, and may very properly alternate 
with the mercurial ; children will bear very large doses of the iodide, and 
indeed they are often necessary if we would get the curative effects of the 
drug ; I would suggest from three to twenty grains three times daily, well 
diluted with water. Both these remedies may be continued for months, but 
ptyalism should always be avoided. Cod-liver oil with extract of malt may 
be administered. Whatever tends to improve the patient' s general condition 
is indicated. Exercise in the fresh air is good, but the pernicious effects 
of cold must be avoided. Paracentesis of the cornea rarely does good, but 
occasionally iridectomy may be of benefit. The complication of iritis or 
irido-choroiditis is not common, though it does occur. When the dis- 
ease becomes very chronic there will be hardly vascularity enough for 
purposes of repair. This being the case, stimulating collyria may be 
used, similar to what is indicated in conjunctivitis. Olive oil and spirits 
of turpentine, in equal parts, may be applied to the eye every second 



TUBERCULOSIS. 143 

day. Bathing- with warm water, sufficiently to congest the eye, will 
sometimes be serviceable. An attack of acute conjunctivitis has been 
known to do good. But do what we may, this affection sometimes runs 
on unchecked for a very long time. From some recent experiences I am 
inclined to believe that bichloride of mercury internally and atropine as a 
collyrium, are of as much value as any other agents in the treatment of 
this obstinate malady. 



CHAPTER III. 

TUBEECULOSIS, 

The term tuberculosis is applied to a disease which is characterized by 
the formation of small nodules, developed, in one or more organs. 

Etiology. — The tubercular diathesis may be inherited. Hence the 
well-known fact of tubercular families. Cases are not infrequent in which 
hereditary tuberculosis proves fatal before the death of the affected par- 
ent. The offspring of a tubercular parent does not, as a rule, have tuber- 
cles at birth ; but the tubercular diathesis, at first latent, as in syphilis, 
manifests itself in a few weeks or months in the formation of tubercles, and 
in the consequent cough and emaciation. In two cases which I recall to 
mind, a cough from tubercles was observed, according to the statement 
of friends, as early as the second or third week after birth. Under good 
hygienic conditions, the inherited diathesis may remain latent or be re- 
moved. If both parents are tubercular, the offspring almost necessarily 
become so. 

Tuberculosis frequently results from prolonged anti-hygienic conditions 
in those previously healthy and of healthy parentage. It may result from 
residence in damp, dark, and dirty apartments, from scanty or unwhole- 
some food, protracted and exhausting diseases — in fine, from any agency 
which gives rise to great and continued impoverishment of the blood. 
Age is a predisposing cause. Tuberculosis is comparatively rare under 
the age of one year, while it is not uncommon in wasted infants between 
the ages of two and five years. This remark is fully substantiated by the 
statistics of the Nursery and Child's Hospital and Infant x\sylum of 
this city. 

Is tuberculosis propagated by infection \ Most physicians would 
answer in the negative, though in some countries, as in Italy, it is stated 
that the profession have long regarded it as mildly infectious. Every physi- 
cian of experience must have remarked the frequency with which tuber- 
culosis occurs in those not predisposed to the disease, but who have been 
in intimate relation with consumptive patients. This has been commonly 



14:4 TUBERCULOSIS. 

regarded as due in no way to infection, but has been thought to be a coin- 
cidence, or has been attributed to an influence not fully understood, which 
the emotions or imagination exert in the causation of diseases. But re- 
cent discoveries concerning the etiology of tuberculosis, which will pres- 
ently be related, afford ground for the opinion, which some of our best 
authorities in the pathology of tuberculosis, as Waldenburg, now hold, 
that minute particles exhaled or expectorated from the lungs may be the 
medium of infection. 

In December, 1865, M. Villemin read before the Academy of Medicine 
of Paris and published his celebrated memoir, which contained the results 
of his experiments in inoculating certain lower animals with tubercular 
matter. Since then the fact has been established by many experiments, 
that tubercle may be produced in the rabbit and other animals by insert- 
ing under their skin various pathological products, whether tubercular or 
non-tubercular, as gray tubercles, cheesy products, thickened pus, etc., and 
by inserting finely divided foreign substances, not animal, as anilin blue, 
and also by traumatic irritations which give rise to the formation of in- 
flammatory products under the skin, as the use of a seton. The coloring 
mattei, whether introduced alone or in combination with a pathological 
substance, is found in the tubercle which results in the lungs or elswehere. 
Therefore, it is inferred that tubercle in these experimental cases is pro- 
duced by minute particles of the inserted substance, which enter the cir- 
culation and are deposited in the lungs or other organs. Where they are 
deposited, inflammation (formative irritation) occurs, with proliferation 
of the cellular elements of the part. This corpusculation produces the 
tubercle. 

The importance of these discoveries is apparent. Cheesy substances 
produced in the system, whether in the lungs, lymphatic glands, bones — 
as in vertebral caries — or elsewhere, and also long retained purulent col- 
lections, as in empyema, may give rise to tuberculosis, provided that par- 
ticles of the diseased substance gain admittance into the circulation. 

Blood extravasated in the alveoli of the lungs, and undergoing degen- 
erative changes, is considered a cause of tuberculosis ; but such extravasa- 
tions are rare prior to the age of puberty. Protracted inflammation of 
the air-passages, as bronchitis or laryngitis, is stated to give rise to tuber- 
cles in certain cases, but it is not easy to see how this could occur except 
when the inflammation has extended to the lungs or given rise to cheesy 
degeneration of the contiguous glands. In infancy and childhood the 
common cause is a diathesis inherited, or acquired through impoverish- 
ment of the blood by previous disease or anti-hygienic conditions, or it is 
infection of the system from cheesy glands or purulent collections. 

Post-mortem examinations in connection with these recent discoveries 
demonstrate that the immediate cause of the formation of tubercles in the 
lungs, spleen, and other viscera, in certain cases, is hyperplasia and cheesy 



ETIOLOGY. 145 

degeneration of the bronchial and mesenteric glands, whether or not this 
glandular affection is to be considered tubercular. Thus in the last two 
cases which I have examined there were minute transparent tubercles in 
the lungs, some becoming yellow, evidently of very recent formation, and 
also in one of the cases in the spleen, while in both cases the bronchial 
glands were enlarged and cheesy, and in one also the mesenteric. In 
another case, occurring in the Child's Hospital, the bronchial and mesen- 
teric glands were cheesy, with all the thoracic and abdominal viscera 
healthy, while there were granulations nearly the size of a pin's head, due 
to cell proliferation, as ascertained by the microscope (tubercular), in the 
pia mater at the base of the brain, along its sides, and between the hemi- 
spheres. 

Cases are less frequent, but are occasionally observed, in which retained 
purulent collections appear to be the cause of the formation of tubercles. 
Thus, in 1870, I presented to the New York Pathological Society the 
lungs, containing minute, recent tubercles, removed from an infant who 
had died when a few months old. The lungs were otherwise healthy, and 
there were no cheesy glands, for which a careful examination was insti- 
tuted ; but in the left thigh was a large, deep-seated abscess, which had 
been detected a month before death. 

Another, and probably the most frequent local cause of tuberculosis, is 
cheesy pneumonia. Caseous degeneration of the inflammatory products 
is common in young and feeble infants affected with pulmonary inflamma- 
tion, and the supposition is reasonable that particles are more readily de- 
tached from a caseous mass in the lungs than in most other situations. 
■Certainly, in this city, cases are not infrequent of young children who pre- 
sent the history of pneumonia, cheesy degeneration, and finally tubercles. 
Many such cases occur during epidemics of measles. 

General Anatomical Characters of Tuberculosis. — Analvsis of the 
blood of tubercular patients shows an increase in the water, albumen, fats, 
and white corpuscles, and a decrease in the number of red corpuscles. 
The fibrin is slightly diminished, except in cases complicated by inflam- 
mation, in which it may be in excess. The chief interest, however, as 
regards the anatomical characters of tuberculosis, pertains to the tubercle. 
The tubercle is as characteristic of tuberculosis as the eruption is of an 
exanthematic fever. It is produced, as already stated, by a local prolif- 
eration or corpusculation produced by the irritation of the tubercular virus 
in the endothelial lining of the lymphatics and bloodvessels, which is now 
regarded as the mother soil of tubercle, instead of the cells of the connec- 
tive tissue as first taught. It is, therefore, a cell-growth, and not a de- 
posit. 

If we examine with a microscope a thin section of a recent tubercle, we 
will observe in its peripheral portion, in which proliferation was active at 
the time of death, large mother cells, spindle-shaped fibro-plastic cells, 



140 TUBERCULOSIS. 

and small round cells, which have been released from the mother cells. 
This zone of proliferation often has considerable extent. Passing toward 
the central portion of the tubercle, we find these small round cells in great 
abundance. They represent a more advanced stage of the tubercle, since 
the central part is oldest. They are the most numerous cells in the tuber- 
cle, and they have been designated the tubercle-cells. They resemble 
closely in appearance the smaller of the white corpuscles of the blood, and 
cannot be distinguished from the normal cells of the lymphatic glands, 
each consisting of a single large nucleus surrounded by protoplasm. They 
are among the most fragile of pathological cells. The cells are held to- 
gether by a transparent adhesive substance, which is firm and resisting. 

Every tubercle tends to undergo a molecular change by which its trans- 
parence is lost. This consists in a decay of the cells and the intercellular 
substance. Granules of fat are deposited within them, and the cells 
shrivel and disintegrate. Fragments of cells, and shrunken cells, and cell- 
nuclei are thus produced, which Lebert described as the tubercle-cells, 
and which were accepted as such by all observers till Yirchow ascertained 
their true character. The molecular change which I have described com- 
mences in the interior of the tubercle, and extends outward till the whole 
tubercle becomes opaque and yellow, and at the same time so friable as 
to be readily crushed between the fingers. The yellow tubercle is there- 
fore only an advanced stage of the gray semi-transparent. 

It is evident that tubercle in its first period possesses vitality, and, like 
all neoplasms, has its bloodvessels. These are soon closed by coagula or 
granular fibrin, mixed with white blood-corpuscles. When the tubercle 
has reached the yellow transformation, its vessels are no longer pervious, 
but it is surrounded by a vascular zone, in which circulation continues. The 
subsequent history of the tubercle is well known. It is seldom, perhaps 
never, absorbed. It softens, and henceforth, as has been said by a Ger- 
man pathologist, its history is that of an abscess. It is an irritant, pro- 
ducing inflammation in the surrounding tissues, with thickening and indu- 
ration, and abundant production of pus-cells, which mingle with the 
tubercle elements. Ulceration and discharge of the liquefied substance 
upon one of the free surfaces is the common result. In exceptional cases, 
instead of softening, the tubercle may undergo fibroid degeneration or 
cretification. 

Anatomical Characters in Infancy and Childhood. — The anatomical 
characters of tuberculosis in the first years of life vary in certain particulars 
from the form which they present in the adult, but after the age of three 
years the differences are fewer and less pronounced than previously. 

Tubercular laryngitis, so common in the adult, is absent in a large pro- 
portion of cases under the age of three years, and when present it has 
little intensity. Ulceration of the larynx very seldom occurs. This has 
been attributed to the fact that there is so little expectoration in young 



ANATOMICAL CHARACTERS. 147 

children, the sputum being an irritant. Niemeyer, however, does not 
consider the sputum of tuberculosis sufficiently irritating to cause laryn- 
gitis and laryngeal ulceration ; but the arguments in favor of this mode 
of causation, in my opinion, more than counterbalance those which have 
been presented against it. 

I have never met a case of tubercular ulceration of the larynx or trachea 
in the post-mortem examination of young children, nor do I recollect ever 
treating a case in which there was that degree of dysphonia which indi- 
cated ulceration. Rilliet and Barthez, in more than 300 necropsies of tuber- 
cular cases, found no ulcers in the larynx or trachea under the age of three 
years ; but met 8 cases between the ages of three and ten years, and 8 be- 
tween ten and fourteen years. The ulcers, whether seated in the larynx or 
in the trachea — and they are in most cases in the former, since the inequali- 
ties upon the surface of the larynx favor the retention of the sputum — are 
commonly small, superficial, round or elongated, and with little thicken- 
ing or inflammation of their borders. Occurring in the folds of the 
mucous membrane, as, for example, around the vocal cords, their form is 
usually elongated. 

Bronchitis is not infrequent. This inflammation is due to, and depend- 
ent on, the pulmonary tubercles, and is therefore most intense in the part 
of the lung where the tubercles are most abundant and farthest advanced. 
Consequently it is more intense on one side than on the other, and it may 
be unilateral. It differs in this respect from idiopathic bronchitis, which is 
commonly pretty uniform on the two sides. It differs also in the fact that 
it is sometimes accompanied by ulcerations. The ulcers are round or 
elongated in the direction of the axes of the tubes, and, like those of the 
larynx or trachea, are superficial. Idiopathic bronchitis of infancy and 
childhood does not cause ulceration. Circumscribed inflammation may 
attack a bronchial tube, as, indeed, the trachea, and give rise to ulceration 
and perforation, from the presence and pressure of a diseased lymphatic 
gland external to the tube. This subject will be treated of hereafter. 

Lungs. — It is well known that in the adult, tubercles are always present 
in the lungs, if they occur in any part of the system. I have met two 
cases in which the lungs were free from tubercles in 36 post-mortem ex- 
aminations of children who died of tuberculosis. One of the two was an 
infant, but its exact age is not stated in the records. It had cheesy de- 
generation of thymus and bronchial glands, enlargement of mesenteric 
glands, but without cheesy degeneration, and disseminated tubercles in 
liver and spleen. The other, fifteen months old at death, had tubercular 
meningitis, with numerous granulations upon the convexity of the brain, 
and the other usual lesions of meningeal inflammation, with bronchial and 
mesenteric glands slightly enlarged and cheesy, and one of the former 
softened. In one case, then, in 18, the lungs had escaped the disease. 
Rilliet and Barthez state that they found the lungs non-tubercular in 47 



148 TUBERCULOSIS. 

cases in 312, and Hillier did in 25 cases in 160. In their cases, therefore, 
the lungs were exempt from tubercles in about 1 case in 7. But it is to 
be recollected that the statistics of these observers were prepared at the 
time when all cheesy degenerations were thought to be tubercular, and the 
bronchial and mesenteric glands are sometimes cheesy when there are no 
tubercles or lesions referable to tuberculosis in any other part of the sys- 
tem. I have records of two such cases, which I reject from my statistics 
of tuberculosis, as there is no evidence that the disease was anything else 
than cheesy inflammation. Did I include these cases, my statistics would 
more closely correspond with theirs. 

Pulmonary tubercles in children under the age of three years are, as a 
rule, discrete, and disseminated through the lungs. In cases at this age, 
which have advanced to a fatal termination, we find yellow tubercles 
from the size of a pin's head to that of a shot in the different lobes ; many 
still semi-transparent if the disease have been of short duration, but if pro- 
tracted most of them yellow, and here and there one softened and sur- 
rounded by condensed fibrous tissue. Around the semi-transparent or 
gray tubercles, many of which were growing, and therefore were in the 
state of active cell proliferation at the time of death, narrow vascular zones 
can often be detected by the naked eye. 

Under the age of three years, tuberculosis exhibits but little tendency, 
perhaps none, to affect the upper lobes sooner or in greater degree than 
the lower. 

The following are the statistics relating to the site of the tubercles in 
the lungs in the cases which I have examined. All, it is to be remem- 
bered, were under the age of three years : — 



Tubercles disseminated throughout the lungs, . . .26 

Tubercles disseminated throughout the two upper lobes, . 3 
Tubercles disseminated through right middle lobe and left 

lower lobe only, ......... 1 

Tubercles disseminated through left upper lobe only, . . 2 
Tubercles disseminated (few and semi-transparent) in left 

lung only, . . 1 

Tubercles disseminated in three points in right, and two in 

left lung, 1 

No tubercles in lungs, 2 

36 

Between the ages of three and fifteen years, statistics show that the 
upper lobes are more liable to tubercles than the lower ; but the differ- 
ence in liability is not great. In many cases occurring in this period, 
the different lobes are affected nearly simultaneously, and not very infre- 
quently the upper lobe is the last which is involved. In October, 1866, 
I made the post-mortem examination of a boy who died in the Children's 
Service of Charity Hospital, at the age of fifteen years, and small scat- 



LUNGS. 149 

tered tubercles were found in the lower lobe of the left lung, while all 
other portions of these organs were healthy. Rilliet and Barthez, who 
include in the same statistics all cases from birth to the age of fifteen 
years, found gray, semi-transparent tubercles 

Cases. 

In the right superior lobe in . 63 

In the right middle lobe in 43 

In the right lower lobe in . . . . . .55 

In the left superior lobe in ....... 65 

In the left inferior lobe in 54 

The same observers found yellow tubercles in the 

Right superior lobe in ........ 40 

Right middle lobe in 28 

Right inferior lobe in 39 

Left superior lobe in ......... 35 

Left inferior lobe in ........ 31 

Tubercle, especially when softening commences, is itself an irritant, 
exciting inflammation around it. Inflammation occurring from this cause 
is obviously likely to be protracted, continuing for weeks or months, un- 
less the tubercular matter be eliminated by ulceration. The highly vascu- 
lar and delicate lungs of the young child are very liable to inflammation 
when they are the seat of tubercles, and as the tubercles are disseminated, 
the pneumonia is commonly more extensive than when it occurs from 
ordinary causes. In fifteen, or nearly one-half of my cases, there was 
pneumonia affecting portions of one or more lobes, or an entire lobe. 
From the extent and position of the solidified portions, it was obvious 
that in most instances the inflammation originated from the irritating 
effect of the tubercular matter, while in others it was due to hypostatic 
congestion, occurring in consequence of the long-continued recumbent 
position and feebleness of circulation. In these fifteen cases the seat 
and extent of the inflammation were as follows : 

Cases. 

Nearly entire right lung, 2 

Nearly entire middle and lower lobe, 1 

Entire left upper lobe, .2 

A considerable part of both lungs, ..... 1 

Posterior parts of both lower lobes, ...... 4 

Posterior part of left lung, 1 

Left lower lobe, and right middle and lower lobes, ... 1 
Left upper lobe (contained a large cavity) and posterior part of 

left lower lobe, ......... 1 

Nodules of inflamed lung around tubercles, .... 2 

The inflammation in about one-third of the cases was due to hyposta- 
sis, as it occurred in depending portions, extended but little into the lungs 
and sustained no relation to the amount of tubercle. It was in the stage 
of red or r more rarely, of gray hepatization. 



150 TUBERCULOSIS. 

In seven of the cases there were pulmonary cavities as large in propor- 
tion as we ordinarily find in tuberculosis of the adult. The seat of one 
was in the right lower lobe ; of two, the left upper lobe ; of one, the 
right upper lobe ; of another, the right lung, its exact seat not stated ; 
and in the remaining case the cavity, which was the largest of all, occu- 
pied the interior of all three lobes on the right side. Some idea of the 
size of these cavities may be learned by the following extracts from the 
records : 1st Case. " A small superficial cavity communicating on one 
side with a bronchial tube, and on the other side with a small circum- 
scribed collection of pus in the pleural cavity." 2d Case. " Cavity of 
the size of a hickory-nut." 3d Case. " Cavity of the size of a large 
hickory-nut. ' ' 4th Case. ' ' Cavity three-fourths of an inch in diameter. ' ' 
5th Case. " A large abscess. " 6th Case. " The cavity occupied nearly 
the whole of the interior of the left upper lobe." 7th Case. " About 
half the right lung excavated into a cavity which extended through the 
three lobes." 

Circumscribed pleuritis, produced by tubercles underneath the pleura, 
was observed in seven cases. It was ordinarily attended by little exuda- 
tion except the fibrin, but in one case a sufficient amount of serum had 
been exuded to compress considerably the lung. Pus was not observed 
in any notable quantity. 

Emphysema was present in several cases, chiefly in the upper lobes, 
sometimes vesicular, with fulness or bulging of the lung, an anaemic ap- 
pearance of it, and doughy, inelastic feel. In other cases emphysema 
was interstitial, producing little bladders of air under the pleura, espe- 
cially toward the root of the lung, or separating the lobules by wedge- 
shaped or irregular interspaces filled with air. In one case air had 
escaped from an emphysematous bladder into the right pleural cavity, 
causing pneumothorax and collapse of the lung. 

Next to the lungs, the bronchial glands are more frequently diseased 
than any other organs, in the tuberculosis of infancy and childhood.* 
They undergo the successive structural changes which characterize glandu- 
lar inflammations, namely, hyperplasia, and more or fewer of them 
cheesy degeneration and softening. In the state of hyperplasia their 
firmness is diminished, and they have a pale flesh-color. Cheesy degen- 

* The term bronchial phthisis has long been applied to that state in which 
the bronchial glands are enlarged and cheesy. Now this glandular disease, we 
have seen, is often the result of inflammation in the strumous ; and while it 
may be the cause of tubercular infection, is probably not, in most instances, 
tubercular itself. But microscopy has not yet drawn the distinction between 
the cells of lymphatic glands, which cause the enlargement by proliferation 
when the glands are inflamed, and the cells of the tubercular neoplasm. They 
appear alike in the field of the microscope. Therefore it seems proper not to 
attempt to distinguish scrofulous glands from tubercular, when they occur in 
a patient affected by tuberculosis. 



LUNGS. 151 

eration commences in one or more points in the gland, sometimes in the 
peripheral, sometimes in the central portion, and it extends till the whole 
gland presents the well-known cheesy appearance. When the gland soft- 
ens, the thick liquid has a puriform appearance, consisting of amor- 
phous matter, fatty particles, and the shrivelled and disintegrated cells of 
the gland. Soon pus-cells occur, and their number increases. 

Rilliet and Barthez state that the bronchial glands were tubercular in 
249 cases in children, while the lungs were tubercular in 265. All 
cheesy glands, it is to be recollected, they considered tubercular. In 4 of 
the 36 cases which I have examined, no record was preserved of the state 
of the bronchial glands ; in one case there was no perceptible hyperplasia 
and no cheesy degeneration ; in two there was hyperplasia, but no cheesy 
degeneration, while in the remaining twenty-nine cases there was cheesy 
degeneration of more or fewer of the enlarged glands, or parts of them, 
with occasional softening. In the fact that the bronchial glands are en- 
larged and caseous, we have an explanation in part of the fact, that the 
symptoms in the tuberculosis of young children differ from those in the 
adult, since Louis found the bronchial glands involved in only twenty- 
eight per cent, of the adult cases of tuberculosis which he examined, and 
Lombard in only nine per cent. A gland pressing upon the recurrent 
laryngeal or pneumogastric nerve, or the trachea, may give rise to dysp- 
noea and a cough ; or on the descending vena cava or one of the venae 
innominatae, to congestion of the brain and meninges, intracranial serous 
effusion, and even thrombosis in the cranial sinuses. The fact that a 
softened bronchial gland is not infrequently eliminated from the system, 
by ulceration, into a bronchial tube or the trachea, is well known. In 
one case which I observed the ulceration had destroyed portions of three 
of the cartilaginous rings of a bronchus, and the aperture was plugged 
by a cheesy fragment of a softened gland which protruded. Occasion- 
ally, it is stated by authors, the ulceration is into one of the large vessels 
of the mediastinum, or even into the oesophagus. 

The following is an example of bronchial phthisis, as it commonly 
occurs. This case, which is not included in the foregoing statistics, was 
seen almost daily by me during its entire progress. On September 3d, 
1874, I examined an infant in the New York Infant Asylum, who had 
wheezing respiration during the last eight days. The wheezing occurred 
both on inspiration and expiration, and also, though less pronounced, 
during sleep ; pulse 96, respiration 40, temperature normal. Its mother, 
who had charge of it, and had till recently wet-nursed it, had unequi- 
vocal symptoms of tuberculosis for several months. The child was pallid, 
and its flesh was soft and flabby. The fauces were perhaps a little redder 
than usual, but were otherwise normal, and a careful exploration of the 
chest revealed no cause of the embarrassed respiration. Auscultation and 
percussion gave a negative result. In the latter part of September a 



152 



TUBERCULOSIS. 



Fig. 11. 




.^PIliiMP 



troublesome diarrhoea occurred, which continued more or less till near 
death. The temperature on September 28th, October 8th, 10th, and 
11th, was 100£°, 100°, 99£°, and 100°. The pulse on October 10th 
and 11th was 120 and 126. On October 8th the percussion-sound over 
the upper part of the right lung seemed somewhat duller than on the 

other side, though the respiration was 
not observed to be notably changed in 
the area of the dulness. There was but 
little cough during the entire sickness. 
Death occurred on October 20th. At 
the autopsy the bronchial glands were 
found enlarged and cheesy, and under- 
neath the right bronchus, near the bi- 
furcation, was a softened, almost dif- 
fluent gland, as large as a small hickory- 
nut, and compressing the bronchus. 
This, no doubt, had produced the 
wheezing respiration, which had been 
the chief local symptom. The lungs, 
spleen, and in less degree the liver, 
contained numerous small miliary tubercles. Certain of the mesenteric 
glands were also cheesy, but to less extent than the bronchial. The 
disease of the bronchial glands was evidently primary, the tubercles of the 
lungs and abdominal organs being apparently quite recent. The accom- 
panying woodcut, from a photograph by Mr. Mason, the photographer at 
Bellevue Hospital, represents a posterior view of the lungs and air-pas- 
sages. 

In no case have I found tubercles in the heart or pericardium, though 
they have been observed in rare instances in the latter. The mesenteric 
glands were enlarged by hyperplasia, and more or less cheesy, in 30- 
cases, were Apparently normal in two cases, while in the remaining 
four cases their condition was not stated. In most of the patients 
the mesenteric glands were small erand less cheesy than the bronchial, but 
in a few instances they were larger than the bronchial and more cheesy. 

It is a noteworthy fact, as bearing on the causative relation of these 
glands to tubercles, that not infrequently the amount of hyperplasia and 
cheesy degeneration occurring in the former was very considerable, while 
the tubercles in the lungs or elsewhere were small, even minute, semi- 
transparent, and evidently of recent formation. It appeared as if in such 
cases the glandular hyperplasia and degeneration, bronchial or mesenteric, 
or both, preceded the general tubercular disease, and probably sustained 
an etiological relation to it. Since the cases which furnished the above 
statistics occurred, my clinical experience with tuberculosis has greatly 
increased, but nothing new or different has been observed at autopsies. 



LUNGS. 153 

Abdominal Viscera. — In children, tubercles in the solid organs of the 
abdomen rarely give rise to appreciable symptoms, since they are small and 
disseminated, not impairing materially the function of the part in which 
they are located. On the other hand, peritoneal and intestinal tubercles, 
and the enlarged and cheesy mesenteric glands, give rise to symptoms 
which require description. The most frequent seat of peritoneal tuber- 
cles is upon the attached surface of the peritoneum, where they are 
formed in the connective tissue. They are distinctly seen through 
the peritoneum, and cause some prominence of it. Exceptionally their 
seat is upon its free surface. Every portion of the peritoneum, whether 
viscera], parietal, or omental, is liable to tubercles, but generally tubercu- 
lization of so extensive a surface does not occur in any one case. The 
tubercles are spherical or lenticular, and most of them small. Sometimes 
they are very numerous, but so minute as to be scarcely visible. They are 
gray or yellow, according to the age. Peritoneal tubercles often produce 
circumscribed peritonitis, causing adhesion of opposite surfaces. The 
tubercles in themselves cannot be detected by palpation ; but masses or 
vlaques composed of tubercles and inflammatory products are sometimes 
so large that they can be felt through the abdominal walls. 

The symptoms of peritoneal tuberculosis are attributable, for the most 
part, to the peritonitis. Among them may be enumerated abdominal 
tenderness or pain, meteorism, ascites — usually slight — and derangement 
of the bowels, commonly diarrhoea. As tubercles in this situation occur, 
in most cases, subsequently to tubercles elsewhere, the symptoms which 
have been described are associated with and are subordinate to others. 

Stomach and Intestines. — The most common seat of gastro-intestinal 
tubercles is the small intestine, and more frequently its lower portion, 
near the ileo-coecal valve, than its upper or central. They are rare in the 
duodenum or contiguous part of the jejunum. They are developed ordi- 
narily in the connective tissue, either that lying under the mucous or the 
serous surface. 

Gastro-intestinal tubercles are often accompanied by ulceration of the 
adjacent mucous membrane. But in a certain proportion of cases there 
is probably no causative relation of the tubercles to the ulcers, for ulcera- 
tion of this membrane is not infrequent in the tuberculosis of children, 
when there are no tubercles in the walls of the stomach or intestines. 
The following statistics of Rilliet and Barthez, relating to this point, will 
aid to an understanding of the symptoms : 

Tubercles in walls of stomach, 7 cases, \ with ulcers ' 6 case8 ' 

( without ulcers, 1 case. 

Ulcers of gastric mucous membrane, without gastric tubercles, 14 cases. 

Tubercles in small intestines, 82 cases, J with ulcers ' 70 cases - 

( without ulcers, 12 cases. 

Ulcers without tubercles in small intestines, 51 cases. 



154 TUBEKCULOSIS. 

Tubercles in large intestine, 15 cases, \ with ulcers ' 10 cases ' 

( without ulcers, 5 cases. 

Ulcers in large intestine, without tubercles, 47 cases. 

The ulcers have vascular, thickened, and infiltrated borders. Their 
diameters vary from a line to half an inch or more, and their general 
form is circular, or, if two or more unite, irregular. Tubercular ulcers 
of the stomach are mostly in the great curvature, those of the small intes- 
tines in the ileum and lower part of the jejunum, and those of the large 
intestine in the coecum. 

The following table exhibits the state of the principal abdominal viscera 
in the 36 cases embraced in my statistics : 

Tubercular, 

Non-tubercular, ..... 

Not stated, 

Fatty, 



iver. 


Spleen. 


Kidneys 


12 


22 


1 


16 


6 


21 


8 


8 


14 


5 









In no instance did I observe tubercular softening in the abdominal 
organs, and a large proportion of the tubercles in the liver, spleen, and 
kidneys were still in the first stage. In the five cases in which the liver was 
recorded fatty, this state of the organ was obvious to the sight, as it is in 
tuberculosis of the adult. A moderate excess of fat in the hepatic cells 
may have been present in some of the other cases, but it was not suffi- 
cient to be appreciable without the microscope. It is to be remarked that 
in the five cases in which the liver was recorded fatty, this organ con- 
tained no tubercles. The spleen is seen to have been the most frequent 
seat of tubercles of all the viscera, except the lungs. In fourteen cases 
the intestines were examined ; and in five, tubercles discovered developed 
in their connective tissue. The intestinal tubercles were small, and ulcera- 
tion had occurred of the mucous membrane which covered them. 

The brain was examined in fifteen cases. In twelve the amount 
of cerebro-spinal fluid varied from §ss to §v, by estimation. In two 
others the records state that there was a considerable amount of this fluid, 
the exact quantity not being given, while in the remaining case conges- 
tion of the brain and meninges was noticed, but nothing was recorded in 
regard to the amount of cerebro-spinal liquid. The increase of the cere- 
bro-spinal fluid in tuberculosis is attributable to wasting of the brain, a 
hydrocephalus ex vacuo, and in some cases to passive congestion and serous 
transudation, due to feeble circulation, or obstructed flow from the pres- 
sure of bronchial glands on the vessels within the thorax, as already 
stated. 

Tubercles were present in the pia mater in three cases : in two with 
fibrinous exudation ; in the other without fibrin or other evidence of in- 
flammation. Tubercular meningitis is described in another part of this 
book. 



ABDOMINAL VISCERA. 155 

Symptoms. — The symptoms in tuberculosis of children arise in part 
from the diathesis, and in part from the tubercles. Before the period of 
tubercles, there are signs of failing health, such as loss of appetite, flabbi- 
ness of the soft parts, or emaciation, lassitude, and loss of strength. 
These symptoms continue after the formation of tubercles, and increase. 

The features are ordinarily pallid, but during the paroxysms of fever, 
to which tubercular patients are subject, they may be flushed. Lividitv 
of the features, due to imperfect decarbonization of the blood, occurs, if 
there be enlarged bronchial glands which compress the vessels within the 
thorax, or if there be extensive pulmonary tuberculization, or pulmonary 
tuberculization, whether extensive or not, which is complicated by capil- 
lary bronchitis or pneumonia. 

The skin is nearly natural, or it loses its flexibility and softness, and 
becomes dry and rough. In some patients there is, at times, general or 
partial furfuraceous desquamation of the skin, due to exaggerated develop- 
ment of the epidermis. Children, like adults, notwithstanding the gen- 
eral dryness of the surface, are liable to perspirations at night and in sleep. 
This symptom is less frequent at the commencement than at an ad- 
vanced period, and in acute than in chronic cases, in young, namely, 
those under three or four months, than in older children. It is more 
abundant about the head and limbs than elsewhere, and is sometimes con- 
fined to these parts. 

Anasarca is not infrequent. It sometimes arises from obstructed circu- 
lation, in consequence of compression of the thoracic vessels by enlarged 
lymphatic glands ; in other cases it is due to diminished plasticity of the 
blood, a result of the tubercular cachexia. The latter is the more com- 
mon cause. It is not an important symptom, on account of the small 
amount of serous transudation, and the character of the parts in which it 
occurs. 

Emaciation, already alluded to, is early, constant, and progressive. 
Under the age of six or eight months it is less marked than in older chil- 
dren, many preserving considerable rotundity of features and form even in 
advanced tuberculosis. The failure of the strength corresponds in amount 
and progress with the emaciation. Slight at first, and exhibited only by 
a degree of lassitude, it gradually increases, till for weeks before death 
the little patient is fatigued by the ordinary muscular movements, and is 
disposed to keep quiet. 

The nervous system is not ordinarily affected except in cases of intra- 
cranial tubercles. In acute tuberculosis, or tuberculosis complicated by 
severe inflammation, there may be agitation and delirium, especially at 
night. 

In most patients the mucous membrane of the buccal cavity presents 
its normal appearance, with the exception of a moist fur upon the tongue, 
and a paler hue than normal of its surface generally. In acute tubercu- 



156 TUBERCULOSIS. 

losis, and in cases complicated by inflammation, the tongue is sometimes 
dry and brown. The appetite may be normal till the close of life, or it is 
poor or changeable. Occasionally it is increased, although the disease is 
progressing. The bowels are regular or relaxed. Diarrhoea may be a 
prominent symptom, even when there are no intestinal tubercles or ulce- 
ration. Meteorism and fulness of the abdomen are common. 

Fever, constant, but usually with evening exacerbation, is rarely absent. 
It continues for weeks or months. During the exacerbation the pulse rises 
to 120, 140, or even to 180 beats per minute, and there is a correspond- 
ing exaltation of the temperature, which in the latter part of the day, 
without inflammatory complication, ranges from 100° to 102° or 103°. 
The febrile movement is a symptom of diagnostic value as regards the 
nature of the disease, though it does not indicate the seat of the tubercles. 

In addition to the symptoms now described, there are special symp- 
toms, due to tuberculization of the different organs. In young children, 
on account of the fact already referred to, to wit, the tendency to a 
generalization of tubercles, there is apt to be a blending of the symptoms 
which arise from different organs, but with care it is not difficult in most 
instances to isolate and refer them to their proper source. The following- 
are the symptoms which arise from tuberculization of the more important 
organs. 

Excephalon. — The symptoms produced by tubercles of the eneepha- 
lon vary according to their seat and size, and the structural changes in 
surrounding parts to which they give rise. Meningeal tubercles, which 
are located for the most part in the meshes of the pia mater, and or- 
dinarily along the course of the small arteries, are, as a rule, small, not 
more than a line in diameter, and they may remain latent for a considera- 
ble time. In the majority of cases, however, they sooner or later cause 
meningitis, the symptoms of which are well known and need not be 
described. But tubercles in this situation do sometimes give rise to 
symptoms when there is no meningeal inflammation. They occasion con- 
gestion of the surrounding vessels, and serous transudation, and, if devel- 
oped on the under surface of the pia mater, they may produce symptoms 
by encroaching upon and irritating the brain ; for they are sometimes so 
much imbedded in the convolutions that careful examination is required 
in order to determine that they are meningeal, and not cerebral. Among 
these symptoms may be mentioned headache, frontal or occipital, some- 
times intermittent, nausea, melancholy, and in certain cases the symptoms 
produced by serous transudation. 

The symptoms of cerebral are in part similar to those of meningeal 
tubercles, but in most cases others of a neuropathic character are 
present, which serve for differential diagnosis. The differences as regards 
the symptoms of different patients affected with cerebral tubercles are 
attributable in part to the fact that their size and rapidity of growth vary, 



SYMPTOMS. 157 

but more to the difference in their seat ; for any part of the brain may 
be the seat of tubercles, though certain portions, as the cerebellum, are 
more frequently affected than others. 

The child with cerebral tubercles is quiet, but irritable and easily ex- 
cited. Delirium is not common, but many before the close of life ex- 
hibit a degree of mental dulness. The headache, common in cases of 
cerebral as well as meningeal tubercles, may be nearly general, or it is 
frontal, parietal, or occipital, according to the seat of the tubercles. It 
is often lancinating, often intermittent. 

Clonic convulsions occur toward the close of life. Exceptionally they 
are among the earliest symptoms. Observations have failed to establish 
any relation between the seat of the tubercles and the localization of the 
convulsions. The convulsions may be unilateral, while the tubercles are 
in both hemispheres ; or general, while the tubercles are on one side 
only. 

The severity and duration of the convulsive attacks, and the frequency 
of their occurrence in tuberculosis of the brain, vary greatly in different 
patients. They have been attributed to softening of the cerebral sub- 
stance, which sometimes occurs immediately around the tubercles, to 
local congestions excited by them, and also to serous effusions in the ven- 
tricles. The convulsions, sooner or later, end in paralysis or coma. 

Contraction, or tonic convulsion of certain muscles, is sometimes 
observed. Its most frequent seat is in the muscles of the back, and of one 
or both of the lower extremities. It is a late symptom. It occurs in 
those cases in which there is softening around the tubercles, and usually 
in the muscles of the opposite side. 

Paralysis is also a late, but not an infrequent symptom. It is preceded 
by headache, and sometimes, as already stated, by convulsions. Occur- 
ring as a symptom of tuberculosis of the brain, it is due either to pres- 
sure on a cranial nerve, or to compression and perhaps softening of the 
cerebral substance. The paralysis may be paraplegic, commencing as 
feebleness of the lower extremities, and increasing until it becomes com- 
plete, or a more or less complete, hemiplegia. In paraplegia due to tuber- 
cles of the brain, the cerebellum is, as a rule, their seat ; while paralysis 
of one side, or of certain muscles of one side, indicates tubercles of 
the opposite cerebral hemisphere ; but there are exceptions. Paralysis 
of the third cranial nerve gives rise to ptosis, of the sixth to paraly- 
sis of the external motor nerves of the eye, and therefore to internal 
strabismus. 

Feebleness or loss of vision, inequality, oscillation, and finally dilatation 
of the pupils, are not infrequent symptoms of tuberculosis of the brain, 
and they possess great diagnostic value. Atrophy of the optic nerve, 
causing amaurosis, sometimes results from tubercles as well as other 
tumors of the brain. Atrophy of this nerve occurs not only when the 



158 TUBERCULOSIS. 

tubercles are so located as to press on the optic tract, in which case the 
explanation is apparent, but also, in certain patients, when the tubercles 
are in other parts of the brain. In these last cases it is thought by 
Brown-Sequard and others that the imperfect nutrition of the nerve is 
due to contraction of its nutrient vessels, produced by the tubercles 
through reflex action. 

In tuberculosis of the brain, symptoms pertaining to the respiratory, 
circulatory, and digestive systems are either absent or are quite subordi- 
nate to those of a neuropathic character. Slowness of the pulse, with or 
without intermittence, has sometimes been observed, and it is therefore a 
symptom of some diagnostic value. Toward the close of life both pulse 
and respiration are apt to be accelerated. Vomiting, constipation, and 
retraction of the abdomen, which are so common in meningitis, are only 
occasional symptoms. 

Bronchial Glands. — During the progress of tuberculosis, hyperplasia, 
cheesy degeneration, and softening may occur of various lymphatic glands 
throughout the body, but the bronchial and mesenteric are not only those 
which are most frequently affected, but they are the only glands, unless 
in exceptional instances, which materially increase the danger or give rise 
to special symptoms. These symptoms either have a mechanical cause, 
namely, the pressure exerted by the enlarged glands on contiguous parts, 
or they are due to softening of the glands and consecutive inflammation 
and ulceration. 

The following are the principal symptoms due to compression. Some 
of them are not infrequent, others are rare. Compression of the pul- 
monary veins retards the flow of blood from the lungs to the left auricle, 
giving rise to congestion, and, in extreme cases, oedema of the lungs, 
with sanguineous extravasations into the lung-substance, congestion of the 
right cavities of the heart, hepatic veins, and of the systemic capillaries 
generally. Compression of the pneumogastric nerve, or of the recurrent 
laryngeal, which is the motor nerve of the laryngeal muscles, modifies th-e 
voice, and produces a cough which is apt to be spasmodic. The cough 
resembles that of pertussis, and has been mistaken for it, but it is not so 
violent or protracted. The voice, clear and natural at first, becomes by 
degrees hoarse or feeble from deficient innervation of the laryngeal mus- 
cles. 

An enlarged gland, or mass of glands, lying against the trachea or one 
of the bronchial tubes (this may occur with tubes up to the third or 
fourth division), and pressing its walls inward, obviously obstructs more 
or less the current of air. If there be considerable obstruction, a loud, 
sonorous rale is produced, which is heard distinctly at a distance from the 
chest, obscuring other rales. It is loudest when the patient is agitated, 
and it sometimes intermits. Feeble respiratory murmur, dyspnoea, and a 
cough are not infrequent in bronchial phthisis. Diminished intensity of 



BRONCHIAL GLANDS. 159 

the respiratory murmur is general or partial, according to the seat of the 
compression. It has been most frequently observed at the summit of the 
lungs. In certain patients this symptom is not constant, the respiration 
being for a time feeble and then normal. The dyspnoea may be a promi- 
nent and distressing symptom, the alae nasi dilating, and the infra-mam- 
mary region sinking with each inspiration. The cough which occurs 
when a gland presses on the trachea or bronchial tube, is due to the 
tracheitis or bronchitis to which the pressure gives rise. If ulceration 
occur at the point of pressure, the cough continues as long as the ulcer 
remains. Compression of the large veins within the thorax, which return 
blood from the head and upper extremities, causes more or less conges- 
tion of these parts, with, perhaps, transudation of serum in the sub- 
cutaneous connective tissue, and within the cranium. Rarely, a softened 
gland by ulceration gives rise to other symptoms than those mentioned, 
namely, haemorrhage by ulceration into a vessel, or pleuritis or pneu- 
monitis if the ulceration be toward the lungs. 

Improvement in the condition of the patient affected with bronchial 
phthisis is not unusual. It may be permanent, but in most patients it is 
temporary, so that in a few weeks or months the symptoms are as severe 
as before. The improvement is due to softening and elimination of a 
gland which had given rise to symptoms by its mechanical effect, or bv 
the inflammation which it had excited. 

Physical Signs. — These are absent or obscure in the incipient disease, 
when the glands are small, and they are most marked in those cases in 
which the glands are so large as to press on the thoracic walls, since 
they then become the medium for the transmission of sounds to the ear. 
The part of the thorax against which they most frequently press is the 
dorsal vertebrae, from the first to the sixth, and each side of the vertebrae, 
and less frequently the upper third of the sternum. The physical 
signs are dullness on percussion over the interscapular space, and perhaps, 
though to a less extent, over the upper part of the sternum, and bronchial 
respiration in the same situations. Occasionally a bruit can be detected, 
due to the pressure of a gland on one of the large vessels of the chest. 

Lungs. — A cough is one of the earliest and most persistent of the 
symptoms of pulmonary tuberculosis. It is so rarely absent, that those 
of largest experience do not meet with more than one or two such cases. 
It varies in severity and frequency. If the tuberculosis be acute and its 
course rapid, the cough, even from its commencement, is frequent, so as 
weary the patient and deprive him of needed rest. But in ordinary cases, 
that is, when the disease is chronic, it commences gradually, attract- 
ing little attention by its infrequency, but becoming more frequent and 
painful as the malady advances. 

Ordinarily the cough is dry in the first weeks or months, but it becomes 
looser in the course of the disease, from the greater amount of bron- 



100 TUBERCULOSIS. 

cliial inflammation. In exceptional instances it has a spasmodic char- 
acter, like that produced by pressure of an enlarged bronchial gland on 
the pneumogastric or recurrent laryngeal nerve. This occurs from the 
accumulation of viscid mucus in one or more of the bronchial tubes, usu- 
ally in dilated portions of them, from which it is with difficulty expecto- 
rated. 

The respiration in pulmonary tuberculosis is accelerated in proportion 
to the degree of tuberculization. Tuberculization of a considerable part 
of both lungs gives rise to dyspnoea, especially when, as is ordinarily the 
case, bronchial, pulmonary, or pleuritic inflammation has supervened. 
Pneumonitis or pleuritis gives rise to the expiratory moan, and as these 
inflammations, when induced by tubercles, are protracted, this symptom 
may continue for weeks or months. 

Patients under the age of six years do not expectorate, or but rarely. 
After this age expectoration is not common in the commencement of pul- 
monary tuberculosis, but in the confirmed disease it is a pretty constant 
attendant of the cough. Haemoptysis is also rare under the age of six 
years, and less frequent subsequently than in the adult. It is most apt to 
occur in those cases in which there is already passive congestion of the 
lungs, produced by the pressure of enlarged bronchial glands in the man- 
ner already described. Patients old enough to make known their subjective 
symptoms, sometimes complain of fugitive pains under the sternum or 
between the shoulders. 

In young children the physical signs of incipient pulmonary tuberculosis 
are wanting, or are so obscure as not to be readily recognized. This is 
due to the small size and dissemination of the tubercles. In older chil- 
dren the physical signs appear early, and are readily recognized, because, 
as a rule, the tubercles are aggregated, and are more frequently at the 
apices of the lungs than elsewhere, as in the adult. In the advanced dis- 
ease, whether in infancy or childhood, when inflammation and more or 
less destruction of the lung-substance have occurred, the physical signs, 
so far from being obscure, enable us in most cases, in connection with 
the history, to make an immediate and positive diagnosis. 

In young children affected with pulmonary tuberculosis the irregular 
and imperfect expansion of the lungs produces by degrees changes in the 
shape of the thorax, which are apparent on inspection. In some, the 
lungs being habitually imperfectly inflated, the obliquity of the ribs is 
increased, and the thorax consequently elongated, while its anteropos- 
terior and transverse diameters are diminished. This obviously increases 
the convexity or arch of the diaphragm, so that this muscle sometimes 
lies against the thoracic walls as high as the ninth or even eighth rib. If 
the costal cartilages are yielding, there is anterior flattening of the chess 
and depression of the sternum ; if they are firm, on account of the more 
advanced age, the chest remains circular. 



PHYSICAL SIGNS. 161 

Another shape of the thorax is not infrequent in feeble tubercular chil- 
dren, especially infants, who have suffered from repeated attacks of bron- 
chitis. It occurs also in the non-tubercular, if the conditions which favor 
it are present. The conditions are, on the one hand, feebleness of the 
patient, with diminished force of respiration and impaired resiliency of 
the ribs ; and, on the other, obstruction by mucus of one or more of the 
bronchial tubes. Occlusion more or less complete, of a bronchial tube, 
and consequent obstruction to the current of air, produces a corresponding 
degree of collapse in the portion of lung to which the tube leads. The 
parts which collapse are, m most cases, the lower lobes, and the thin 
anterior margins of the upper lobes. This causes lateral depression of 
the lower ribs, except such as are pressed outward by the abdominal vis- 
cera, and an anterior projection of the lower part of the sternum. The 
shape of the thorax in these cases differs from that in rachitis, in the fact 
that the lateral depression does not extend to the upper ribs, nor does the 
upper part of the sternum project. 

Certain precautions should be observed in examining the chest by per- 
cussion and auscultation. The child should sit or recline, with the arms 
and shoulders in the same position, and the axis of the trunk straight. 
Inclination of the trunk to either side, raising or depressing a shoulder, 
may produce an appreciable difference in the two sides as regards the 
physical signs. Percussion of the two sides should be practised at the 
same stage of respiration. A slight difference in the degree of resonance 
does not afford proof of disease, unless it be observed at different exami- 
nations ; for, in feeble children, it often happens that all portions of the 
lungs do not expand alike, so that where we have noticed slight dullness 
at one visit, it may by the next have disappeared, or even at the same 
visit, if forcible inspirations be excited. 

The physical signs ascertained by palpation, auscultation, and percus- 
sion are, as in the adult, vocal fremitus, bronchial respiration, bron- 
chophony, and dullness on percussion. In those cases in which the tuber- 
cles are mainly at the apices of the lungs, diminished expansion of the 
infra-clavicular region is observed during inspiration, and this part of the 
thoracic wall is permanently depressed, so tint the clavicles are unusually 
prominent. If there be emphysema, this flattening does not occur, or is 
slight. Dullness on percussion, though more frequently observed in the 
infra-clavicular region than elsewhere, may be present in different isolated 
places. If pneumonia supervene, the dullness not infrequently extends 
over a considerable part of one lung. The cracked-pot sound is often 
observed on percussion, but it possesses no diagnostic value. It can be 
produced, w r hen there is no pulmonary disease, by percussing over a 
bronchus. 

Bronchial respiration and bronchophony are important signs, as indi- 
cating solidification of the lung, but they do not show whether the solidi- 



162 TUBERCULOSIS. 

fication be tubercular or pneumonic, or the two conjoined. This must be- 
determined by the history of the case, the extent of surface over which 
these signs are heard, and their persistence. When the tubercles begin 
to soften, and the lung-tissue breaks up, moist rales appear, often hoarse- 
and gurgling, obscuring the bronchial respiration. A cavity in the lung,, 
or pneumothorax, is attended by the same physical signs as in the adult. 

Pleura. — Little need be said in reference to the symptoms and phy- 
sical signs of tuberculosis of the pleura, since this affection is in most in- 
stances associated with tuberculosis of the lungs, and is not distinguishable 
from it. But now and then the pleural tubercles are numerous and 
large, giving rise to symptoms, while those of the lungs are small, few,, 
and without symptoms, or attended by symptoms which are quite subor- 
dinate. Either the costal or visceral portion of the pleura may be the 
seat of tubercles. They are developed directly under the pleura, or 
upon its free surface. They are very apt to occur in the newly formed 
connective tissue which results from pleuritis. Those located upon the 
free surface, or under the costal pleura, rarely soften, while those under 
the visceral pleura sometimes soften and cause ulceration. Occasionally- 
numerous aggregated tubercles form a firm, continuous layer upon the 
surface of the pleura, preventing, if upon the visceral pleura, full expan- 
sion of the lung. This may give rise to a degree of dullness on percus- 
sion, and feebleness of the respiratory murmur. Ordinarily, however, in 
this form of tuberculosis, the symptoms and physical signs, so far as any 
are observed, are due to the pleuritic inflammation w T hich the tubercles- 
excite. 

Stomach and Intestines. — The symptoms in tuberculosis of the stom- 
ach and intestines vary according to the seat and stage of the tubercles. 

Tubercles, whether gastric or intestinal, are not at first accompanied 
by symptoms, or the symptoms are obscure and ill-defined. Symptoms , 
arise when inflammation occurs in the adjacent tissues. Diarrhoea is one' 
of the most common and persistent of the symptoms. The alvine dis- 
charges are brown and thin, and sometimes, in advanced cases, very 
offensive. They may be streaked with blood which has escaped from the- 
ulcers. Intestinal tubercles, developed immediately underneath the peri- 
toneal coat, sometimes cause local peritonitis, usually of little extent. This- 
gives rise to circumscribed pain, tenderness, and more or less meteorism. 

Diagnosis. — It is evident from the foregoing description of symptoms- 
that the diagnosis of incipient tuberculosis is much more difficult in chil- 
dren than adults. Before commencing the examination, it is advisable to^ 
learn the hereditary tendencies of the family and the history of the 
patient, especially as regards antecedent diseases or debilitating agencies, 
and the duration of the symptoms. 

Tuberculosis of the encephalon is diagnosticated with more difficulty 
than that of the thoracic or abdominal organs ; but certain of these organs- 



PHYSICAL SIGNS. ' 163 

are ordinarily tubercular at the same time, and the knowledge of the fact 
that they are affected aids in the diagnosis of the disease of the brain or 
its meninges. Among the symptoms which possess diagnostic value may 
be mentioned cephalalgia and more or less fever, with exacerbations in the 
commencement of the disease, and, at a more advanced period, strabismus, 
inequality or irregular action of the pupils, impairment of vision, retrac- 
tion of the head, and convulsive movements or paralysis. 

In certain cases careful observation and discrimination of symptoms are 
requisite, in order to determine whether they arise from intra-cranial 
tubercles, or from congestion of the brain caused by obstruction in the 
venous circulation by the pressure of enlarged bronchial glands. 

The diagnosis of bronchial phthisis, when the glands are still small, is 
necessarily uncertain, on account of the absence of symptoms. When they 
have increased in size and are so located as to press on the pneumogastric 
or recurrent laryngeal nerve, producing the spasmodic cough already de- 
scribed, the differential diagnosis between that disease and pertussis may 
be made by attention to the following facts : Bronchial phthisis occurs 
singly, and is non-contagious, while pertussis occurs as an epidemic, and 
with evidences of contagion. There are no successive stages, to wit, 
those of catarrh, paroxysmal cough, and decline, as in that disease, and 
the cough, though paroxysmal, is short, and without whoop or vomiting. 

In feeble children, with inherited tubercular diathesis, emaciation, 
sweats, and a chronic cough, with the absence of pulmonary symptoms, 
should excite suspicions that the bronchial glands are involved. The evi- 
dence is almost conclusive if the cough become paroxysmal, and there 
be a loud, persistent, tracheal or bronchial rale. 

In certain of the patients affected with this form of tuberculosis, we 
have seen that the prominent symptoms are due to compression of one or 
more of the large vessels in the chest. Compression of these vessels, and 
consequent retarded circulation, may be confidently referred to enlarged 
bronchial glands, since aneurism, carcinomatous or other tumors, which 
would produce a similar result, are very rare before puberty. Sometimes 
the diagnosis is rendered certain by the physical signs observed by auscul- 
tation, and percussion over the sternum and the interscapular space. The 
condition of the external glands should also be observed, as those of the 
axilla, neck, and groin. 

The diagnosis of pulmonary, though more readily made than that of 
intra-cranial and bronchial tuberculosis, is often difficult and uncertain. 
This is, in part, explained by the fact that the tubercles are so frequently 
disseminated, while emaciation and a chronic cough are not infrequent 
from other causes than tubercles. Rachitis, intestinal worms, dentition, 
simple tracheal or bronchial inflammation, may be attended both by a 
chronic cough and emaciation. Caution is therefore requisite in order to 
avoid a grave error in diagnosis. Precipitancy in the diagnosis of doubt- 



164 • TUBERCULOSIS. 

fill cases is worse than indecision, and it is often best to postpone an ex- 
pression of opinion as to the nature of the disease, till the case has been 
observed for a few days. 

The significance and importance of the symptoms, physical signs, and 
other facts on which a diagnosis must be based, have already been suffi- 
ciently pointed out. It is difficult, in fact in certain cases impossible, to 
discriminate between' simple cheesy pneumonia and cheesy pneumonia 
which has ended in the formation of tubercles. The patient has an at- 
tack of catarrhal pnemuonia ; but, instead of absorption of the inflam- 
matory product, cheesy infiltration occurs, and the lung in places becomes 
infiltrated with pus, softens, and breaks down. The patient presents the 
symptoms and physical signs of phthisis. He may recover after a pro- 
tracted sickness, or may die. The disease may, and often does, remain 
a pneumonia ; but this is a condition of the lungs which favors the devel- 
opment of tubercles, and in a certain proportion of cases tubercles do 
form in the last weeks of life. Though the differential diagnosis in such 
cases between cheesy pneumonia and tuberculosis supervening on pneu- 
monia is impossible, practically the discrimination is unimportant, as the 
same treatment is required. 

Advanced pulmonary tuberculosis, except when it supervenes upon 
pneumonia, can in most instances be readily diagnosticated by a careful 
examination. Still, it is to be recollected, as already pointed out, that 
certain of the symptoms and physical signs, which occurring in the adult 
would afford almost positive proof of pulmonary tuberculosis, not infre- 
quently have a different origin in children. 

The diagnosis of tubercles in the abdominal organs is facilitated by the 
presence of symptoms which indicate at the same time tuberculosis of the 
lungs. Among the chief diagnostic signs of tuberculosis of the peritoneum 
may be mentioned meteorism and a degree of tenderness on pressure, but 
there is danger of mistaking the tympanitic state of the intestines com- 
mon in ill-nourished infants and the rachitic, or the fullness due to en- 
larged spleen or liver, for that occasioned by peritoneal tuberculization, 
and vice versa. The history of the case, and a careful examination of ac- 
companying symptoms, and the shape and feel of the abdomen, usually 
suffice to establish the diagnosis. In simple gaseous distension of the 
abdomen there is an absence of the symptoms, general and local, which 
attend tuberculosis ; rachitis occurs at an earlier age than peritoneal 
tuberculosis, and digital examination, aided by percussion, enables us to 
diagnosticate enlargement of the liver or spleen. 

Tubercular enlargement of the mesenteric glands cannot be positively 
diagnosticated when they are small. When they have attained such a size 
that they can be felt through the abdominal walls, palpation, in connec- 
tion with the history and symptoms of tuberculosis, suffices to establish 
the diagnosis. The glandular tumors can be diagnosticated from other 



DIAGNOSIS. 165 

tumors by the fact that they are tender on pressure, and occupy the um- 
bilical region, v/hile faecal tumors are not tender, and are located in the 
iliac or lumbar region. Gastro-intestinal tuberculosis cannot be positively 
diagnosticated. Protracted diarrhoea, or frequent attacks of diarrhoea, 
not readily controlled by medicine, and occurring in tubercular cases, are 
probably associated with intestinal ulceration ; but in only a certain pro- 
portion of cases of ulceration are there also tubercles in the walls of the 
intestines, as we have seen above. 

Prognosis. — Death is the ordinary result of tuberculosis in the child, 
as it is in the adult ; but now and then one recovers. Hospital statistics 
show that the average duration of the disease is from three to seven 
months. Under favorable circumstances it is more protracted, even to 
two or three years. Those succumb soonest who inherit a strongly 
marked tubercular diathesis, live in damp, dark, and ill -ventilated apart- 
ments, and whose diet is scanty or of poor quality. Therefore in the poor 
quarters of the city tuberculosis presents a worse form and pursues a more 
rapid course than among families in better circumstances. 

Favorable prognostic signs are absence of tubercular diathesis, good 
appetite and general health, with little emaciation, infrequencv of cough, 
with respiration, pulse, and temperature nearly normal. Such symptoms 
may afford hope of recovery with judicious regimenal and therapeutic 
measures. On the other hand, if the symptoms be grave, death is in- 
evitable, unless in bronchial phthisis, in which, even when there is con- 
siderable urgency of symptoms, the offending gland is sometimes elimi- 
nated by softening and ulceration, and the patient improves temporarily, if 
he do not ultimately recover. Complete and permanent recovery is, 
however, quite exceptional. 

Death in tuberculosis of children may occur from exhaustion induced 
by the general disease, or from the local effect of the tubercles. Thus, 
in intra-cramal tuberculosis it may result from coma ; in pulmonary 
tuberculosis, from dyspnoea, though more frequently from exhaustion ; 
in that of the bronchial glands, from coma, dyspnoea, exhaustion, or even 
from hemorrhage ; in that of the abdominal organs, from peritonitis or 
protracted diarrhoea. 

Treatment. Prophylactic. — Since caseous substance occurring in some 
part of the system is the common cause of the development of tuber- 
cles, it is evident that measures which tend to prevent the occurrence of 
this substance are prophylactic of tuberculosis ; and since, in children, 
cheesy matter, in most instances, is a product of strumous inflammations, 
the anti-strumous remedies are demanded in the prophylactic as well as 
curative treatment of tuberculosis. Therefore, the strumous child should 
be watched with great care, and such measures be employed as are calcu- 
lated to invigorate its system. If the mother belong to a decidedly 
tubercular family, or give the history of scrofula in her childhood, it 



166 TUBERCULOSIS. 

is better that she do not suckle her infant, but employ a healthy wet- 
nurse. Children who are weaned should have plain, but nutritious and 
easily digested diet, a part of which should be milk. Residence in an 
airy and salubrious locality, out-door life, a scrupulous avoidance of ex- 
posure by which a cold might be contracted, are important, in order to 
the continued latency of the diathesis. 

Loss of flesh or appetite, or other evidences of failing health, indicate 
the need of other measures of a therapeutic character. Alcoholic stimu- 
lants should now be allowed three or four times daily in milk ; cod-liver 
oil, with half its quantity of syrup of the lactophosphate of lime, to 
which the syrup of the iodide of iron is added, will be found useful for 
these cases, as it is in the ordinary forms of scrofula. The various bitter 
preparations containing iron, as the citrate of iron and quinine, elix. 
calisaya bark with iron, etc., should be employed, when, for any reason, 
cod-liver oil is not tolerated. By the employment of such precautionary 
measures as soon as indicated, multitudes of children might be saved from 
tuberculosis who now perish. 

Curative. — The medicinal agents which are required in ordinary cases 
have been already mentioned, namely, cod-liver oil, iron, sometimes the 
vegetable tonics, and alcoholic stimulants. The oil may be given in 
emulsion to disguise the unpleasant flavor, or, which I prefer, mixed with 
half its quantity of syrup of the lactophosphate of lime, as recommended 
for the treatment of scrofula. 

If the cod-liver oil be not tolerated, or if it impair the appetite, it 
should be discontinued. In cases of diarrhoea it is of little or no benefit 
and may do harm. Under such circumstances patients sometimes do 
better with simple regimenal measures, aided by alcoholic stimulants, and 
one of the least unpleasant of the tonics, as wine of iron or the calisaya 
bark. The regimen already recommended for prevention is also required 
as a part of the curative treatment. 

Certain modifications of treatment are demanded on account of the 
localization of the tubercles. Intra-cranial tuberculosis, as soon as 
diagnosticated, should be treated by pretty decided doses of iodide of 
potassium, though, unfortunately, there is little prospect of improvement. 
The glandular disease, whether bronchial or mesenteric, requires the 
iodide of iron, with or without that of potassium. Pneumonitis or pleu- 
ritis, so frequent a complication of pulmonary tuberculosis, requires emol- 
lient poultices, with moderate counter- irritation, and the judicious use of 
opiates with stimulants. The peritonitis occurring in abdominal tubercu- 
losis, which is usually circumscribed, is best treated by fomentations and 
poultices, with opiates, and the diarrhoea by subnitrate of bismuth and 
chalk, five to ten grains of each, or the bismuth with Dover's powder, or 
a more active astringent. 



SYPHILIS. 167 



GHAPTEE IV. 

SYPHILIS. 

Syphilis in infancy and childhood presents itself under two forms, 
namely, the congenital and acquired ; the former is the more frequent. 

Etiology. — Congenital syphilis may be derived from either father or 
mother. Either parent, having previously had syphilis, may transmit it 
to the offspring, although at the time free from syphilitic symptoms. 
The mother, healthy at the time of conception, but infected with syphilis 
prior to the eighth month of gestation, may communicate the disease to 
the foetus ; syphilis contracted in the eighth or ninth month does not 
affect the foetus. If both parents have syphilis, the infant is almost 
•necessarily syphilitic ; on the other hand, if only one parent be affected, 
the infant may or may not be contaminated. Sometimes, with such 
parentage, a part of the children are syphilitic, and a part healthy. 

Acquired syphilis in infancy and childhood may be received through 
primary lesions — that is, by reception of the virus from a chancre or 
bubo ; or it may be derived from certain of the secondary lesions. In- 
oculation by primary lesions may occur at the birth of the infant, from a 
syphilitic sore in the vagina or upon the vulva of the mother ; inoculation 
in this manner is, however, rare. Children may also receive the virus 
from primary lesions on the persons of nurses or companions. Infection 
in this manner is sometimes accidental, and sometimes the result of 
^criminal conduct. A chancre on the breast of the wet-nurse not very 
infrequently communicates syphilis to the nursling. 

The contagiousness of " secondary manifestations," for a long time 
doubted, is now fully established. Syphilis may be communicated by 
the secretion or exudation of a mucous patch, or a secondary sore. Hence 
the danger of lactation bv unhealthy wet-nurses, though they present no 
symptoms of recent syphilis. Excoriations or sores upon the nipple or 
•breast of an infected wet-nurse may communicate the disease to the nurs- 
ling ; and, on the other hand, mucous tubercles or fissures upon the lips 
or tongue of the infected infant may be the means of contaminating a 
healthy wet-nurse. Many such cases are now contained in the records of 
medicine. Vaccination by means of the scab is also a mode by which 
constitutional syphilis may be communicated. For further particulars in 
reference to this subject the reader is referred to our remarks on vaccina- 
tion. 



168 SYPHILIS. 

Clinical History. — The effects of the syphilitic poison upon the de- 
velopment of the foetus, and the development and health of the infant,, 
are different in different cases. The foetus, under the influence of the 
poison, often ceases to grow, shrivels, dies, and is expelled, long before 
term ; or it may be born alive, but prematurely, and showing clear evi- 
dences of the disease, as soon as it comes into the world ; or, asrain, it 

/ 7 7 J5 7 

may be born at term, but dead. So frequently is syphilis a cause of non- 
viability, that, as Trousseau has remarked, this disease should be suspect- 
ed as the cause, whenever a woman repeatedly aborts. Abortion from 
syphilis commonly occurs at or about the sixth month of gestation. In 
those cases in which the foetus dies from syphilis there is often placental, 
syphilitic disease, namely, an undue growth of cells in the villi, which,, 
compressing the vessels, gives rise to fatty degeneration, and prevents the 
requisite interchange between the maternal and foetal blood. (Herring,. 
Frankell.) Frankell designated the change " granulation-cell hypertrophy 
of the placental villi." Virchow, in one case, found a gummy tumor in. 
the maternal portion of the placenta. 

When a foetus destroyed by syphilis is expelled, it is apt to present a 
macerated appearance, the cuticle being detached over large patches of 
surface, and in other parts raised in blebs, with a thin, puriform, and 
offensive fluid underneath ; the liver is occasionally indurated, and ab- 
scesses with spots of inflammation are sometimes observed in the thymus 
gland ; the amniotic fluid is offensive, turbid, and of a greenish or green- 
ish-brown appearance. 

If the foetus, in which syphilitic manifestations have begun to occur,, 
have reached a viable age, and be born alive, it is small and imperfectly 
developed, often shriveled and senile in appearance. The skin looks un- 
healthy, and it may exhibit a distinct rash. Bouchut saw a seven and a 
half months' infant born alive, with an eruption of a copper color upon 
the legs and arms, and onyxis upon the fingers and toes. The bullae of 
pemphigus are also not infrequent upon the skin at birth, or they appear 
within a few days, two or three, after birth. The smallest are about the 
size of a split pea ; but many are considerably larger ; the largest consist, 
of two or more which have coalesced. They contain a thin, green- 
ish, purulent matter, and appear most frequently upon the palms of the 
hands and soles of the feet, but also in severe cases upon the face and 
over the surface of the body. Recently I was able to diagnosticate syph- 
ilis in an infant within a day after birth, by its small size and feebleness^ 
and the appearance of large blebs of pemphigus upon its hands, feet,, 
fingers and toes, over which the skin soon broke, leaving troublesome and 
bleeding sores ; coryza commenced about the twelfth day. The parents 
seemed healthy, but I was enabled to trace the syphilitic taint to the 
mother. Non-syphilitic pemphigus, the result of cachexia, sometimes 
appears soon after birth, but its primary and usual seat is around the 



CLINICAL HISTORY. 169 

neck, and upon the body. I have known it to appear within the first 
week of life, and end fatally by the close of the second week. I have 
not found it difficult to distinguish it from syphilitic pemphigus by the 
history of the family, and its absence from the palmar and plantar sur- 
faces of the hands and feet. Condylomata, mucous patches, and stains 
of a copper color are the principal syphilitic affections, besides pemphigus, 
which have been observed at birth on the bodies of contaminated infants. 
It is stated that M. Cullerier, in ten years' attendance at the Hopital de 
Lorraine, met only two cases of syphilitic manifestations at birth, and 
Victor de Meric only two cases in forty-six infants, who were affected 
with congenital syphilis (Bumstead) ; but in the practice of others a 
larger proportion have exhibited symptoms at birth. Ordinarily the 
period in which congenital syphilis is first revealed by symptoms is be- 
tween the fifteenth and fortieth days. Rarely the manifestation of the 
disease is delayed several months. M. Diday ascertained the time of the 
commencement of symptoms in 158 cases as follows : 

Before the completion of one month after birth, in . . .86 

two " " '« . . 45 

three " " " " . . . 15 

At four months, 7 

' five " .1 

' six ".......... 1 

' eight " .1 

' one year 1 

' two years, 1 

In cases of tardy commencement of syphilitic symptoms it is probable 
that the poison has been partially eradicated from the affected parent by 
appropriate treatment. 

The nutrition of the infant who has inherited the syphilitic taint, but 
does not exhibit it at birth, is for a time good, but it begins to be im- 
paired when the local manifestations of syphilis appear, or soon after. 
The system gradually wastes ; the skin loses its fresh and healthy ap- 
pearance, and becomes sallow, and, after a time, more or less wrinkled ; 
the features become pinched and contracted, and wear a sad expression. 
M. Diday says : " Next to this look of little old men, so common in 
new-born children doomed to syphilis, the most characteristic sign is the 
color of the skin." Trousseau thus describes this discoloration of the 
surface : " Before the health becomes affected, the child has already a 
peculiar appearance ; the skin, especially that of the face, loses its trans- 
parency ; it becomes dull, even when there is neither puffiness nor 
emaciation ; its rosy color disappears, and is replaced by a sooty tint, 
which resembles that of Asiatics. It is yellow T , or like coffee mixed with 
milk, or looks as if it had been exposed to smoke ; it has an empyreu- 
matic color, similar to that which exists on the fingers of persons who are 



170 SYPHILIS. 

in the habit of smoking cigarettes. It appears as if a layer of coloring 
had been laid on unequally ; it sometimes occupies the whole of the skin, 
but is more marked in certain favorite spots, as the forehead, eyebrows, 
chin, nose, eyelids — in short, the most prominent parts of the face ; the 
deeper parts, such as the internal angle of the orbit, the hollow of the 
cheek, and that which separates the lower lip from the chin, almost always 
remain free from it. Although the face is commonly the part most 
affected, the rest of the body always participates more or less in this tint. 
The child becomes pale and wan." 

The infant whose system is profoundly affected by syphilis rarely 
smiles, and its voice is feeble and plaintive ; its frequent, whimpering cry 
is quite characteristic. 

Coryza is one of the earliest and most constant of the local affections 
which occur in infantile syphilis. It is slight at first, attracting little at- 
tention from the parents, who are not aware of its significance, and 
usually attribute it to a slight cold ; but it gradually increases. It gives 
rise to a secretion from the Schneiderian membrane, at first thin, but 
which becomes more consistent, and is attended by the formation of 
scabs. The thickening of the mucous membrane, in consequence of the 
inflammation and the presence of crusts, narrows the passage through the 
nostrils so as to produce snuffling respiration, and sometimes render nurs- 
ing difficult. In severe cases respiration through the nostrils is almost 
wholly prevented, so that death may occur from inanition, unless the 
breast be milked into the infant's mouth, or it be fed with a spoon ; but, 
ordinarily, even in grave coryza, it continues to nurse, though obliged 
often to release its hold of the nipple to obtain breath. It is when coryza 
begins to interfere with lactation that it first alarms the parents. The 
inflammation at the same time may affect the throat and larynx, causing 
hoarseness of the voice. Ulceration of the Schneiderian membrane and 
the adjacent cartilage or bone is rare in infancy or childhood, although 
cases occur which are even attended with more or less flattening of the 
nose. Diday believes that the discharge which accompanies coryza 
is in great part due to mucous patches developed on the Schneiderian 
membrane. The upper lip, over which the discharge flows, becomes 
red, excoriated, and more or less incrusted. The coryza, in most cases, 
coexists with other local syphilitic affections. Occasionally it occurs 
alone, and is the only evidence of the presence of the specific taint, 
except such as is afforded by the mal-nutrition and general appearance of 
the patient. 

Mucous patches occur in most patients. They are developed either 
upon the mucous surfaces, or upon parts of the skin which are thin and 
exposed to friction, and such as are moistened by secretion or transuda- 
tion from the vessels underneath. The most common seat of mucous 
patches is at the termination of mucous canals ; but in infancy, on account 



MUCOUS PATCHES. 171 

of the peculiar delicacy of the skin, they may occur upon almost any part 
of the cutaneous surface. They are most common, however, around the 
anus, upon the vulva, scrotum, umbilicus, labial commissures, in the 
axillae, and behind the ears. 

Mucous patches upon the skin present a rounded border, and are slightly 
elevated. Their color has been compared to that of the skin which has 
been softened by the prolonged application of a poultice. Erosions and 
cracks sometimes occur in the patches, from which a thin liquid 
exudes. 

Upon mucous surfaces they are less elevated than upon the skin, and 
are prone to ulcerate. These ulcerations, commencing at the centre, ex- 
tend, and soon the mucous patch disappears, and its site is occupied by 
an ulcer. The ulcer may be circular, oval, elliptical, crescentic, or irregu- 
lar. The arches of the fauces are a common seat of mucous patches. 

Roseola is an occasional symptom of infantile syphilis. " It is dis- 
tinguished," says Diday, "by patches of a bright rose-color, circum- 
scribed, irregularly rounded, of various sizes (most frequently about as 
large as one of the nails) ; appearing, by preference, on the belly, lower 
part of the chest, neck, and inner surface of the extremities." The 
spots do not readily and fully disappear by pressure. 

Pemphigus appearing soon after birth has already been alluded to. 
Its most frequent seat, whether occurring after birth or as a subsequent 
manifestation, is, as we have stated, the palms of the hands, soles of the 
feet, the fingers, and toes. This eruption commences by a violet tint of 
the skin, and in the course of twenty-four to forty- eight hours a watery 
fluid collects underneath, which soon becomes turbid. The skin peels 
off, and sometimes an angry sore results, which bleeds readily when 
rubbed or pressed. In other and more favorable cases new skin takes 
the place of that which is lost. Pemphigus at birth is a precursor of 
death, but when it appears for the first time some weeks after birth, it is 
a less unfavorable prognostic sign. In cases of recovery it disappears, 
with proper treatment, in two or three weeks. 

Acne, Impetigo, and Ecthyma are occasionally observed in children 
afflicted with syphilis. The indurated pustules of acne occur most fre- 
quently upon the shoulders, back, chest, and buttocks. The pus is 
sometimes absorbed, and in other cases discharged, leaving a small 
cicatrix, which, after a time, disappears. Impetigo appears most frequently 
upon the face, and occasionally upon the chest, neck, axilla, and groin. 
Unlike simple impetigo, the syphilitic impetiginous eruption is surrounded 
by a copper-colored areola. Ecthyma occurs upon the legs and buttocks 
chiefly. It commences as violet-colored spots, which are soon trans- 
formed into pustules. Ulcers succeed, which, in reduced states of the 
system, are apt to enlarge and endanger the safety of the child. Of the 
three pustular eruptions, acne, according to Diday, is the least serious-^ 



172 SYPHILIS. 

indicating a " less confirmed diathesis." Ecthyma is the most serious, 
on account of the reduced state of system with which it is apt to be asso- 
ciated. Syphilitic papulae and squamae are rare in infants, but cases have 
been observed. Onychia occasionally occurs, though less frequently than 
in syphilis of the adult. 

Visceral Lesions. — The visceral lesions which result from the syphilis 
of infancy and childhood are, suppuration in the thymus gland ; gummy 
tumors in certain organs, most frequently the lungs and liver ; increase 
of the connective tissue of the liver, known as syphilitic cirrhosis ; 
partial perihepatitis, with depressions resembling cicatrices on the sur- 
face of the liver ; peritonitis ; periostitis, with thickening of the bone 
and exostosis. 

Suppurative inflammation in the thymus gland is not common, or has 
not been frequently observed. When it is present the gland sometimes 
presents its normal appearance externally, and the abscess is only discov- 
ered by incisions. Gummy tumors are white and spheroidal ; some are 
as small or smaller than a piu's head, while others are as large as a pea, 
or even a hazel-nut. I have seen a considerable number of them not as 
large as a pin's head, in the liver of an infant. Gummy tumors, accord- 
ing to Lebert, consist ' ' of loose fibrous tissue, made up of pale, elastic 
fibres, inclosing in their large interspaces a homogeneous granular sub- 
stance, the elements of which are less adherent to each other than in de- 
posits of true tubercle. " Lebert also, with other microscopists, discov- 
ered round granular cells in these tumors. According to Robin, gummy 
tumors " are made up of rounded nuclei belonging to fibro-plastic cells, 
or cytoblastions ; of a finely granular, semi-transparent, and amorphous 
substance ; and, finally, of isolated fibres of cellular tissue, a small num- 
ber of elastic fibres, and a few capillary bloodvessels. ' ' 

Constitutional syphilis is one of the principal causes of waxy degenera- 
tion, and the spleen and liver of infants may be enlarged from this cause. 
Dr. Samuel Gee has expressed the opinion that in half the cases of 
hereditary syphilis the spleen is enlarged. (London Lancet, April 13th, 
1867.) 

Infiltration of the liver by fibrous substance was first noticed by Giib- 
ler. It is not common in the infant. A specimen, showing this lesion, 
was presented to the London Pathological Society in 1866, by Dr. 
Samuel Wilks. The following remarks by Dr. Wilks convey a good idea 
of the appearance and state of the liver in syphilitic cirrhosis : " Having 
dissected the bodies of several infants who have died of congenital syphi- 
lis, I have found fatty livers, and an inflammation of the capsule ; but in 
only two have I discovered adventitious products of a fibrous character. 
The present example, however, corresponds in every particular with the 
disease described by Gtibler. It must be distinguished (at least as far as 
the naked-eye appearance reaches) from the syphilitic disease of adults, 



VISCERAL LESIONS. 173 

of which many specimens have been before the Society. In these the 
organ is cicatrized on the surface, and contains distinct nodules of fibrous 
tissue ; while in the disease of children, as in the present specimen, the 
whole organ is infiltrated by a new material, and it consequently becomes, 
as described by Giibler, hypertrophied, globular, and hard, resistant to 
pressure, and even when torn by the fingers, its surface receives no in- 
dentation from them ; it is also elastic, and when cut, creaks slightly 
under the scalpel. This was the form of disease in the present speci- 
men. It came from a syphilitic child, a month old, in whom the liver 
could be felt enlarged during life, and when removed weighed a pound 
and a half. It was smooth on the surface, and so hard that it resembled 
rather a fibrous tumor than a liver. It is seen that the liver in the 
syphilitic child is liable to three distinct pathological processes, namely, 
gummy tumors, cirrhosis or fibroid degeneration, and waxy degeneration." 

Syphilitic perihepatitis and periostitis are more rare in infancy and 
childhood than in adult life, but they occasionally occur. The late Sir 
James Y. Simpson considered peritonitis in the foetus one of the results 
of syphilis, and a cause of its death. 

Osseous Lesions. — Within the last few years, important discoveries 
have been made in regard to the effect of syphilis upon the nutrition of 
the bones in children. In 1870, Dr. Wegner, of Berlin, published his 
observations of the state of the skeleton in twelve syphilitic children, who 
were either stillborn, or who died within a few days or weeks after birth. 
He found clear proof that the syphilitic dyscrasia very frequently disturbs 
the nutrition and produces anatomical changes in the skeleton of the 
foetus. The following are the lesions, clearly referable to syphilis, which 
he observed : periostitis of long bones, including the ribs ; softening, 
separation, and sometimes crepitation, at the point of union of diaphysis 
and epiphysis ; chalky concretions and infiltrations along the line of ossi- 
fication ; fatty degeneration of marrow ; irregular formation and distribu- 
tion of spongy substance in the epiphysis. These lesions were not all 
observed in each case, but they occurred with such frequency that there 
could be no doubt that they were due to the syphilitic taint of system. 
Confirmatory observations also, in twelve cases, have since been made by 
Waldeyer and Kobner.* 

Again, there is a syphilitic lesion of the bone in children, which is not 
usually present or has not usually been observed at birth, but is devel- 
oped in the first weeks or months of infancy. The lesion alluded to is a 
circumscribed enlargement of one or more bones. This has been most 
frequently observed upon the long bones, including the clavicle and ribs ; 
but in certain children it occurs upon other bones in addition. In some 

* See elaborate paper by R. W. Taylor, M.D., New York Journal of Obstet- 
rics, etc., July, 1874. 



174 



SYPHILIS 



cases it is one of the first manifestations of hereditary syphilis, occurring 
even sooner than the coryza, while in others several months elapse before 
it appears. In one case, reported by Dr. Bulkley,* of this city, it was first 
seen only a few days after birth, being perhaps congenital ; while in 
another case, in which the enlargement was upon certain phalanges, and 
which is represented in the accompanying figure, it appeared at the age of 
twelve months. When it occurs upon a phalangeal bone, it is designated 
dactylitis syphilitica. 

The enlargement, if upon a long bone, ordinarily begins at or near the 
point of union of the diaphysis with the epiphysis. It is located upon 
the extremity of the shaft which it encircles, and it extends over a part 
or nearly the whole of the epiphysis. It has an elevation of perhaps one 
half or three quarters of an inch in typical cases ; its surface is smooth, or 
slightly undulating, and the skin over it, though distended, has its normal 
appearance, and is easily movable, unless ulcerations have occurred. 

These enlargements, which result from the specific inflammation occur- 
ring in the periosteum and the bone, 
may resolve under proper treatment ; 
but if neglected, and the anti -hy- 
gienic conditions are bad, degenera- 
tive changes may occur, ending in 
ulceration and destruction of the dis- 
eased part to a greater or less extent. 
Though these bone enlargements, 
whenever observed, should excite 
suspicions of syphilis as the cause, 
enlargements which present the same 
general appearance do occur from 
other causes. Such a case was ob- 
served by me in the children's class 
in the Outdoor Department of Belle- 
vue, and Dr. Bulkley details another 
case in his paper. In the case ob- 
served by me, the inflammation and 
enlargement seemed to be strumous. 
Baumlersays : " Dactylitis syphilit- 
ica docs not always originate in the bone ; similar appearances may be 
produced through gummous formation in the sheaths of the tendons, and 
in the fibrous structure of the finger ;" and again, " Its outward appear- 
ance may be produced also by tuberculosis, enchondroma, or sarcoma 
of the bone-marrow." (Art. Syphilis, Ziemssen's Encycl.) 

Mr. J. Hutchinson, of London, has called attention to the fact that 




* Rare Cases of Congenital Syphilis, New York Med. Journal, May, 1874. 




PEOGNOSIS — TREATMENT. 175 

hereditary syphilis, having perhaps been manifested by the usual symp- 
toms during infancy, and then becoming latent, may give rise to new 
symptoms after the fourth year. The most p IG , ^ 

noticeable of these symptoms is a dwarfing 
of the permanent incisor teeth, which are 
rounded and peg-like, and their enamel 
notched at the free ends of the teeth. On 

account of the small size and shape of the W| :\ I k \ A 
teeth, there are interspaces between them. 
This abnormal development is most marked in the central incisors of the 
upper jaw, and in certain cases it is limited to them, and it never appears 
in the other incisors unless it does also in them. Another symptom, 
which only appears in hereditary syphilis, is an interstitial keratitis occur- 
ring on both sides, and attended by the deposition of fibrin in the sub- 
stance of the cornea. In a few weeks the inflammation declines, but a 
slight opacity of the cornea remains. The cerebral nerves may become 
affected, usually a single pair — if the auditory, deafness resulting ; if the 
optic, dimness of sight. Occasionally there are other manifestations of 
syphilis in this period, as enlargement of spleen and liver, and nodes 
upon the long boues. 

Prognosis. — This depends in great part on the general condition of 
the patient. If there be much emaciation, and the symptoms indicate a 
deeply-seated cachexia, a considerable proportion perish. On the other 
hand, if the general health be not greatly impaired, although the local 
affections are pretty severe, the prognosis with correct treatment is good. 
The younger the infant, when the symptoms of syphilis appear, the more 
unfavorable, as a rule, is the prognosis. 

Treatment. — Parents who beget syphilitic children ought, from a 
due regard for their offspring, to make use of antisyphilitic remedies, 
although they present in their persons no evidences of syphilitic taint. 
A good prescription for the parents is one-sixteenth of a grain of corrosive 
sublimate in the compound tincture of bark, given twice or three times 
daily for several weeks. If the father have had syphilis, both parents 
should be subjected to this treatment, and it may be continued, at least 
on the part of the mother, during the first months of her gestation. So 
small a dose of the mercurial does not, in my opinion, materially increase 
the liability to miscarry. There is much more danger of miscarrying 
from allowing the syphilitic taint to remain uncontrolled. Some prefer 
the use of mercurial ointment in the treatment of pregnant women for 
syphilis, in the belief that it is less likely to produce abortion. It is used 
for this purpose in the proportion of one drachm to the ounce. It is 
equally effectual in the eradication of the syphilitic taint with the small 
dose of corrosive sublimate recommended above for internal administra- 
tion ; but it is impossible to determine the quantity of mercury which 



176 SYPHILIS. 

enters the circulation when inunction is employed, and salivation is more 
likely to occur. 

Syphilis in the infant requires mercurial treatment as in the adult. 
Mercury may be employed internally or by inunction. Some prefer 
inunction in the treatment of ordinary cases in the manner recommended 
by Sir Benjamin Brodie. ' ' I have spread, ' ' says he, ' ' mercurial oint- 
ment, made in the proportion of a drachm to an ounce, over a flannel 
roller, and bound it round the child once a day. The child kicks about, 
and, the cuticle being thin, the mercury is absorbed. It does not either 
gripe or purge, nor does it make the gum sore, but it cures the disease. 
I have adopted this practice in a great many cases, with the most signal 
success." Trousseau, on the other hand, discountenances the use of 
inunction, as mercurial ointment applied to the skin produces irritation, 
and increases the suffering and restlessness of the child. He prefers the 
following solution, which is known as Van Swieten's, for internal treatment : 

I£. Hydrarg. bichlorid., 1 part ; 
Aquas, 960 parts ; 
Spts. rectific. 100 parts. Misce. 
Dose, one, or at most two grammes (15.434 to 30.868 grains), in milk, daily. 

In order to avoid the risk of establishing a diarrhoea, and to leave the 
stomach free for the employment of other medicines, as cod-liver oil and 
the iodide of iron, I prefer and commonly prescribe for infants inunction 
with the mercurial ointment diluted with eight times its quantity of lard, 
cold cream, or vaseline. It should not, in my opinion, be applied as a 
plaster, but a quantity of the size of a large chestnut should be rubbed 
three times daily upon the neck or breast of an infant of three or four 
months. For children over the age of eight or ten months, Van Swieten's, 
or one of the following formulae may be employed : 

r> . Hydrarg. cum creta, gr. iij-vj. 
Sacch. alb., 3j. Misce. 
Divid. in chart. No. xii. One powder 3 times daily. 
r>. Hydrarg. chlor. corros., gr. j-ij. 
Syr. sarsae comp., | ij. 
Aquae, 5 viij. Misce. 
One teaspoonf ul 3 times daily. 

3. Hyd. chlor. corros., gr. ss. 
Potas. iodid., 3j. 
Ferri et ammon. citrat., 3 j. 
Syr. simplic, § vj. Misce. 
Dose, one teaspoonful 3 times daily for a child of 3 to 5 years. 
]£. Hyd. chlor. corros., gr. j. 
Potas. iodid., 3 ij. 
Syrup, simplic, 
Aquae, aa | ij. Misce. 
Dose, six drops 3 times daily for a child of 3 months. 



TREATMENT. 177 

Mercury, in whatever way employed, should not be discontinued 
-entirely till several weeks after the syphilitic symptoms have disappeared ; 
it is proper to continue it for a time, in diminished quantity and fewer 
doses, after the health seems fully restored. 

When the mercurial is omitted, tonics are often required. The prepa- 
rations of cinchona are useful in certain cases, as are also those of iron. 
If the patient remain feeble and pallid, presenting evidences of struma, 
cod-liver oil and syrup of the iodide of iron will be found beneficial con- 
tinued for some weeks or months after the mercurial is discontinued. 
Attention should always be given to cleanliness and the hygienic manage- 
ment of the patient. In some instances direct treatment of the local affec- 
tions is serviceable. To aid in the cure of syphilitic coryza, the follow- 
ing ointment should be applied within the nostrils by a nasal sponge three 
times daily : 

I£. Ung. hydrarg. nitratis, 3 ij. 
Ung. zinci oxidi, § ij. Misce. 

Recently I have been in the habit of employing Squibb's oleate of mer- 
cury, two per cent, for syphilitic coryza of infants, and the effect has been 
satisfactory. It may also be employed by cutaneous inunction in the treat- 
ment of the general disease. 

Condylomata or mucous patches seated upon the cutaneous surface 
may be dusted with calomel. At my clinique, in April, 1871, a child 
two years and ten months old was presented, with a large condylomatous 
outgrowth near the anus. The history of the child showed that in all 
probability the disease had been contracted within a year from syph- 
ilitic children in one of the public institutions. Within three weeks this 
affection disappeared by dusting upon it calomel once daily, with appro- 
priate internal treatment. 



SECTION II. 

ERUPTIVE FEVERS. 



CHAPTEK I 

MEASLES. 



The disease known in the vernacular as measles has also the names 
rubeola and niorbilli. It is a common exanthematic affection, occurring 
at any age, but most frequently in childhood. It affects once the- 
majority of mankind. Writers recognize three stages of measles : first, 
that of invasion, which ends with the appearance of the eruption ; sec- 
ondly, the eruptive stage ; and thirdly, the stage of decline or desquama- 
tion. 

Symptoms. — This disease commences with such symptoms as usually 
occur in mild but pretty general inflammation of the air-passages, namely, 
cough, fever, anorexia, and thirst. The eyes present a suffused, mod- 
erately injected, and brilliant appearance, and the buccal and faucial sur- 
faces are injected. The Schneiderian membrane, and that lining the 
larnyx, trachea, and bronchial tubes, participate in the increased vascu- 
larity. The cough at first is dry, and sometimes distinctly croupy\ 
Catarrhal or false croup, indeed, is not infrequent in the initial period 
of measles. The cough is attended by slight acceleration of respiration, 
and by little or no pain in the respiratory movements. If auscultation be 
practised at this early stage, we observe the vesicular murmur, somewhat 
harsh in character, and sometimes sonorous and sibilant rales. A little 
later, rales of a moist character appear. 

The patient, if old enough, commonly complains of headache, and of 
dull pain in the epigastric region, or the centre of the sternum, due to 
the bronchitis. With these local symptoms febrile reaction occurs. The 
temperature rises to about 102° or 103°, as indicated by the thermometer 
in the axilla. The pulse numbers from 110 to 130 per minute. The 
fever is somewhat greater than in primary tracheo-bronchitis, except when 
the bronchitis extends to the bronchioles, but it is less than in most cases 
of scarlet fever. 

The fever in the premonitory stage of measles after the first day is not 



SYMPTOMS. 179 

uniform. It is attended by remissions and exacerbations, the former 
occurring in the first part of the day, the latter in the evening. Some- 
times two exacerbations occur in the day. The face is flushed and some- 
what swollen, especially during the times of increase in the fever, and the 
child is drowsy or restless. Vomiting, so common a symptom in the 
commencement of scarlet fever, occasionally occurs in measles. While 
in scarlet fever this takes place in the first twenty-four hours, in measles 
it occurs with about equal frequency at any period previously to the 
eruption. It was present during the first stage, sometimes almost as 
late as the eruptive period, in thirteen, and was absent in twenty-three 
cases, in which I preserved records in reference to this symptom. 

The duration of the first stage varies in different cases. It is usually 
from two to five days, with an average of about four. Occasionally it is 
more protracted on account of some disturbance in the economy, either 
from exposure to cold or other cause, which prevents the necessary afflux of 
blood toward the surface, and retards the eruption. In eighteen cases in 
my practice in which the duration of the cough previously to the appear- 
ance of the rash was accurately ascertained, the time varied from one to 
five days, with an average of three and one third ; in ten other cases it 
had continued, the parents stated, about a week, and in five, from one to 
two weeks, previously to the eruption. 

The eruption commences, when the disease pursues its normal course, 
upon the forehead and neck, then the face, and gradually extends down- 
ward, occupying from twenty-four to thirty-six hours in passing over the 
trunk and limbs. It appears first as indistinct red points, not more than 
a line in diameter, which increase in size and become more distinct. 
Their borders are uneven or irregular, or they are finely notched ; their 
general shape is, however, circular, except as two or more unite, when 
they may assume any form. The crescentic form which writers describe 
is due to the union of two points of eruption. The largest of these spots 
when there is no coalescence, do not exceed a quarter of an inch in 
diameter, and many are much smaller. Frequently in plethoric children, 
if there be much fever, there is continuous redness over several inches of 
surface. The eruption is then confluent. This form is often observed 
upon parts of the surface where the capillary circulation is most active, 
when it is discrete elsewhere. In some of these cases, diagnosis of 
measles from scarlet fever is attended with difficulty. 

The rubeolous eruption is slightly elevated. This is not appreciable to 
the sight, but can be ascertained by passing the finger slowly over the 
skin, when a little roughness is felt at the point of eruption. Sometimes 
the elevation, especially in the commencement of the efflorescence, is not 
appreciable, even to the touch. The eruption is broad and flat, never 
acuminate, never changing its form to the vesicular or pustular. It dis- 
appears by pressure, and immediately reappears when the pressure is 



180 MEASLES. 

removed. It has been compared in appearance to flea-bites. Small, 
pointed, papular, vesicular, or pustular eruptions are sometimes seen in 
connection with those of measles, but they are accidental, occurring in 
other states of system, as well as in measles, if there be the same aug- 
mented temperature. 

In the commencement of the eruptive period the severity of the consti- 
tutional and local symptoms increases. The pulse and temperature corre- 
spond with the character which they presented during the exacerbations 
of the first stage. The features are slightly swollen ; the eyes still 
watery and sensitive to light ; the conjunctiva, ocular and palpebral, and 
the mucous membrane of the cavity of the mouth and of the air-passages, 
continue injected. The tongue is covered with a moist thin fur, and its 
papillae are prominent, though less so than in scarlet fever. The cough 
continues frequent, and is seldom attended with much expectoration, in 
uncomplicated cases ; often there is no expectoration whatever. The 
appetite is lost, but drinks are readily taken on account of the thirst. 
Diarrhoea sometimes occurs on the first day of the eruption, but it lasts 
only a few hours, and, if the disease pursue its usual course, abates of 
itself. With the exception of this the bowels are regular, or a little con- 
stipated during the eruptive period. 

On the second day of the eruption, or sixth of the fever, the symptoms 
begin to abate. The pulse is less accelerated, and the temperature dimin- 
ishes ; the cough is less frequent and is easier, and the flushed and 
swollen appearance of the face declines. By the close of the third or on 
the fourth day the rash has disappeared in the order in which it extended 
over the body. There only remain faint maculae, which in the course of 
a day or two fade completely. 

With the disappearance of the rash the fever nearly or quite ceases, but 
a slight and painless cough continues for several days. 

Occasionally the eruption presents a livid appearance ; this is the 
rubeola nigra of writers. From cases which I have observed, it is my 
opinion that this should not be considered a distinct species in the vast 
majority of patients, but that the dark color is due to internal inflammation, 
usually capillary bronchitis or pneumonia, which prevents full decarboniza- 
tion of the blood. Rarely rubeola nigra is due to the vitiated state of the 
blood, or the malignant nature of the disease. The course of the eruption 
in this form of measles is somewhat different ; it continues longer, fades 
more slowly, and does not disappear so readily on pressure. Traces of 
it are observed a week or more after its first appearance ; it is apt to be 
fatal. Measles may present this form from the beginning, or, com- 
mencing as vulgaris, it may pass into rubeola nigra. 

Measles may be irregular in form, but aberrations are less frequent 
than in scarlet fever. Writers describe measles without catarrh, and, on 
the other hand, with catarrh but without the rash. But positive diag- 



COMPLICATIONS. 181 

nosis in such cases must be difficult. It is probable that simple catarrh 
and roseola have sometimes been mistaken for the two forms of irregu- 
larity mentioned, but when a child, in a family of children affected with 
measles, presents all the symptoms of that disease, except the catarrh or 
except the eruption, the diagnosis of irregular measles would, as a rule, 
be correct. 

Occasionally the stage of invasion is very short, or even absent. In 
one case the parents informed me that the catarrhal symptoms began on 
the day when the eruption appeared. Convulsions sometimes occur at 
the commencement of measles, as well as during its progress. A single 
convulsive attack at the commencement of measles is usually not danger- 
ous ; when repeated, it is more serious ; it is also more serious when it 
occurs in the course of measles. In certain patients the eruption appears in 
an irregular and partial manner, occurring, perhaps, at a late period, and 
indistinctly, upon the trunk alone, or upon the trunk and partially upon 
the legs. In many cases of deferred or partial eruption there is internal 
congestion or inflammation of some part, which causes withdrawal of 
blood from the surface, and thus prevents the normal development of the 
rash. 

When the eruption disappears the third stage commences, that of des- 
quamation. It is characterized by a scanty furfuraceous exfoliation of 
the epidermis. The desquamation is seldom as great as in scarlet fever, 
and it occurs most where the eruption has been thickest and the epider- 
mis most inflamed. Exfoliation occurs between the fourth and seventh 
days after the commencement of the eruption, the eighth and the elev- 
enth of the disease. In some children it does not take place, or is so 
slight as not to be observed. 

With the disappearance of the rash, the symptoms rapidly abate. The 
pulse becomes more natural, the temperature is reduced, the digestive 
organs return to their normal state, and convalescence is established. 
The cough continues several days after the other symptoms abate, but it 
is less and less frequent, and is not painful. 

Complications. — The complications of this disease are important. 
Much of the success of the physician in the management of measles 
depends upon a correct diagnosis and understanding of them. The most 
frequent of these complications are bronchitis and broncho-pneumonia. 
Slight bronchitis is common in measles, but if it increase so as to cause 
embarrassment of respiration, and become a source of danger, it is prop- 
erly a complication. This complication, as well as pneumonia, may occur 
at any period of measles ; but it commences most frequently in the first 
stage. Occurring in the first stage, it may prevent the regular appearance 
of the rash ; if in the second, it often causes retrocession of it. 

When bronchitis becomes really serious, it usually has invaded the 
minute bronchial tubes. This disease designated capillary bronchitis or 



182 MEASLES. 

suffocative catarrh, I have elsewhere described. The clinical history of 
fatal bronchitis, as a complication of measles, is as follows : The respira- 
tion, at first not notably altered, becomes, by degrees, accelerated, and 
the patient more and more fretful. The pulse, instead of becoming less 
accelerated, as after the first days of simple measles, is daily more rapid, 
and the respiration more frequent and labored. The dyspnoea gradually 
increases, the infra-mammary region is depressed, during each inspiration, 
and the subcrepitant rale is heard on both sides of the chest. There is, 
probably, collapse or inflammation of some of the lobules. Finally the 
prolabia and fingers become livid, and death occurs from apnoea. Capil- 
lary bronchitis is diagnosticated from pneumonitis by the physical signs. 
It is in the young child more dangerous than that disease, unless per- 
chance the latter be double. A large majority of those affected under the 
age of three years, die. The anatomical characters of fatal bronchitis 
occurring in connection with measles, I have had an opportunity to 
inspect. In an infant who died with this complication in the Infants' 
Hospital in the spring of 1867, there were evidences of continuous 
inflammation from the epiglottis to the minutest bronchial tubes. 

Pneumonia as a complication does not differ materially from the idio- 
pathic inflammation, except that it is more protracted and fatal. Its form 
is in most cases catarrhal, resulting from an extension downward of the 
bronchitis. 

The next most frequent serious complication of measles is entero-colitis. 
This may commence at any period during the course of the disease. If 
the colon be more especially the seat of inflammation, the evacuations 
contain mucus and blood, unless in young children, in whom the stools, 
even in severe colitis, commonly have a green color. The anatomical 
character of this complication varies in different cases, like the idiopathic 
form of inflammation. Sometimes there is simple arborescence of the 
intestinal mucous membrane, with tumefaction of its follicles ; in other 
cases, in addition to increased vascularity, the mucous coat is softened 
and thickened ; and in others still, especially if the inflammatory action 
have been somewhat protracted, ulceration occurs, for the most part in the 
site of the solitary glands. Exceptionally, in fatal cases of measles 
attended with diarrhoea, no vascularity is observed after death, although 
the intestine may be somewhat thickened and softened. In these cases 
the diarrhoea may have been non-inflammatory or inflammatory, the 
injection of the vessels having disappeared after death. 

Severe and obstinate diarrhoeal affections occurring with measles, 
usually commence as the primary disease is about declining. They then 
become sequelae, ending fatally in many instances several days or perhaps 
weeks after the disappearance of the eruption. Diarrhoeal attacks, occur- 
ring in, or previously to, the eruptive stage, are, as a rule, mild and 
easily relieved. 



COMPLICATIONS. 183 

In some grave cases, measles have a tendency from the first to affect 
the internal organs more than the surface. There then coexist bronchitis, 
pneumonia, and entero-colitis, with indistinctness of the eruption on the 
skin. Such complications render a fatal result highly probable. 

Another very fatal complication and sequel is true croup, commencing 
when rubeola is beginning to decline ; but it is less frequent than pneu- 
monia or entero-colitis. In catarrhal or false croup, which, as has been 
previously stated, is not infrequent at the commencement of measles, the 
-cough has a loud, ringing character. In true croup, on the other hand, 
it is hoarse or harsh, and less distinct, on account of the presence of the 
pseudo-membrane in the larynx. True croup, always a grave disease, is 
more serious when it occurs as a complication of measles than in the 
idiopathic form, not only because the blood is vitiated and the system 
Teduced by the primary affection, but because the inflammation of the 
mucous surface is in general more extensive, as is also, I believe, the 
pseudo-membrane. This membrane in the croup of measles I have seen 
extend so far down the air-passages, that tracheotomy could not have 
been attended by any decided amelioration of symptoms. This complica- 
tion, though always grave, is not, however, necessarily fatal. I have 
known cases recover by inhalation of spray, when for days there had been 
dyspnoea and other evidences of a pretty firm pseudo-membrane. True 
■croup causes continuation of the fever, which had perhaps begun to 
abate. 

Diphtheria, when epidemic, also frequently complicates measles. Much 
of the mortality from measles in this city, since the year 1858, was due 
to this cause. In cases observed by myself, diphtheria usually began 
while the fauces were still inflamed, and sometimes before the eruption 
had begun to fade. 

These are the most common complications of measles. There are 
•others of less frequent occurrence, among which may be mentioned conges- 
tion of the brain, with or without serous effusion. Stomatitis, pharyn- 
gitis, and otitis are occasional complications. Rarely, also, purpura, 
attended by haemorrhages from the different mucous surfaces, occurs in 
•connection with measles. This complication is, however, more frequent 
in certain other constitutional diseases, as scarlet fever, and especially 
variola. 

It is seen that the inflammations which are apt to occur in the course 
of measles are chiefly of the mucous surfaces. In scarlet fever, on the 
other hand, the inflammations are more frequently serous. 

There are other affections, originating in measles, which are rather 
sequela) than complications. Gangrene of the mouth is one which, as 
stated in another part of this book, is more apt to occur after measles 
than any other disease. After a severe epidemic of measles in the New 
York Foundling Asylum, in 1874, three cases of gangrenous vulvitis 



184 MEASLES. 

occurred in those who had been affected. Ophthalmia commencing in 
measles often persists for weeks or months. It may give rise to granula- 
tion of the lids, and cases have been reported of violent inflammation of 
a purulent character, producing ulceration of the cornea, and destroying 
vision. The ophthalmia is sometimes very intractable. Inflammation of 
the Schneiderian membrane, commonly present during measles, often 
continues as a sequel, extending back as far as the Eustachian tube, 
where it may cause swelling, Avith impairment of hearing, and forward to 
the lip, where it may produce chronic eczema. 

Anatomical Characters. — I have made, or witnessed, mainly in the 
institutions, several post-mortem examinations of those who have died 
in, or immediately after, an attack of measles. In all there were lesions 
due to complications. Indeed, death directly from measles is so rare 
that few have had an opportunity of studying the anatomical characters 
which are peculiar to this affection. In those who have died without any 
obvious coexisting disease, and these cases chiefly occur in the malignant 
form, there has been congestion of the internal organs, especially marked 
in the lungs, and sometimes the tissues appeared softened. The blood, 
also, in the malignant form, has a darker hue than natural, and ecchy- 
motic patches have been observed upon the mucous surfaces and else- 
where, corresponding in character with the petechias under the skin which 
sometimes occur in this form of measles. In cases resulting fatally from 
bronchitis or pneumonia the bronchial glands are commonly tumefied in 
the same manner as the mesenteric glands are enlarged in enteritis, and 
the glands of the mesocolon in dysentery. 

Nature. — Rubeola, like the other exanthematic fevers, is due to a 
materies morbi, the exact nature of which is unknown. It is highly con- 
tagious through the air. It has been inoculated by the serum from vesi- 
cles which sometimes occur in connection with the rubeolous eruption, 
and also by the blood from a patient. Inoculation does not appear to 
moderate the disease, and as measles, when contracted in the ordinary 
way, is not in itself dangerous, but dangerous only from complications, 
inoculation is not performed, except as a matter of scientific interest. The 
usual mode of propagation is through the air. It is communicated both 
by the breath and clothing. By fomites the virus is sometimes conveyed 
a long distance. The question is still undecided whether rubeola does 
not sometimes occur spontaneously. I have met cases, and have heard of 
others, one in a sparsely settled district, in which there was no evidence 
of exposure. Yet the immunity of certain islands for centuries, till 
infected through commerce, renders the doctrine of an origin de novo 
improbable. 

Twelve to fourteen days elapse from the time of infection to the com- 
mencement of the eruption. In cases observed in the children's depart- 
ment of Charity Hospital, the incubative period was ascertained to be 



TREATMENT. 185 

about twelve days. In those who have been inoculated, this period is said 
to have been about one week. Rubeola prevails epidemically, like the 
whole class of infectious diseases, and in different epidemics the type 
varies somewhat, as well as the character of the complications. 

Diagnosis. — The diagnosis of measles, previously to the eruption, is 
often difficult. The catarrhal symptoms then predominate, and these are 
such as may occur independently of any constitutional or blood disease. 
The first stage, therefore, is not infrequently mistaken for coryza, or 
mild bronchitis. The points of differential diagnosis are the suffused 
appearance of the eyes, the greater degree of fever on the first day than 
would be likely to arise from so moderate an amount of local disease, 
and morning remission and evening exacerbation of the fever. Measles 
in the first stage has been mistaken for remittent fever. The catarrhal 
symptoms should prevent such an error. 

Sometimes roseola closely resembles measles in appearance, but the rash 
of roseola appears within a few hours after the commencement of febrile 
symptoms, and almost simultaneously over the whole body, and without 
those local symptoms referable to the mucous surfaces, which characterize 
measles. 

Variola on the first day of the eruption has sometimes been diagnosti- 
cated measles. I recollect once being called to an infant with fatal 
confluent smallpox, who was said to have measles. A physician, a few 
days previously, observing the red points in the commencement of the 
eruption, had made this absurd diagnosis, and, predicting a favorable 
result, had not thought it necessary to repeat his visit. In case of doubt, 
it is the part of prudence to defer making a positive diagnosis. A few 
hours suffice to show the distinctive characters of the rubeolous and vario- 
lous eruptions. But the anxiety of friends often necessitates the expression 
of an opinion. The absence or lightness of catarrhal symptoms, the earlier 
appearance of the eruption, and its papular feel under the finger in small- 
pox, enable us to discriminate between the two diseases in the commence- 
ment of the eruptive stage. Moreover, the symptoms in the initial periods 
are different, as will be seen in our description of smallpox. 

Prognosis. — This is favorable, provided that there is no serious com- 
plication. With internal inflammatory complication, on the other hand, 
the disease becomes much more grave. A large proportion thus affected 
die. The prognosis is also less favorable in feeble children with scanty 
eruption, or an eruption appearing at a late period and irregularly. Dysp- 
noea, persistent and great acceleration of pulse, and coma, indicate an 
unfavorable ending. Convulsions occur much more rarely in the course 
of measles than in scarlet fever, and when they occur after the initial 
period they usually end in coma and death. 

Treatment. — Uncomplicated measles require no medicinal treatment 
except to palliate symptoms. The child should be kept in an airy apart- 



186 MEASLES. 

ment, at a uniform temperature of about 70°. A temperature so elevated 
as to be uncomfortable to the nurse is injurious to the patient. But 
while the popular idea is erroneous, that he should be kept in a heated 
atmosphere, it is correct that currents of air and sudden reduction of 
temperature are dangerous. A violent and fatal attack of croup occurred 
in my practice in a girl of fifteen, in consequence of exposure at an open 
window at the close of the eruptive stage. The diet should be mild, and 
for the most part liquid. The patient, indeed, refuses solid food, but, 
on account of the thirst, takes liquids more readily. Farinaceous sub- 
stances, with milk, afford sufficient nutriment in ordinary cases. If the 
previous health have been poor and the vital powers reduced, or if there be 
a complication, more sustaining diet is required. Stimulation by wine or 
brandy is needed in these cases. During the two or three weeks succeed- 
ing an attack of measles, care should be taken to avoid exposure to cold, 
or changes of temperature, since during this period there is great liability 
to inflammations of the mucous surfaces. 

The cough ordinarily requires treatment, inasmuch as the suffering of 
the child and loss of sleep are largely due to this symptom. Demulcent 
drinks, as flaxseed tea, infusion of slippery -elm bark, or solution of gum 
Arabic, are useful, to which, to render them more palatable, lemon-juice 
may be added. A small Dover's powder, or the mistura glycyrrhizse 
compositus of the pharmacopoeia, given occasionally, relieves the severity 
and diminishes the frequency of the cough. 

As the chief danger in measles is from inflammation of the respiratory 
organs, local treatment directed to the chest is important. The chest 
should be covered with oil silk, unless in the mildest cases. This in- 
creases the amount of eruption upon the surface underneath, and, I believe, 
tends greatly to prevent complication by bronchitis and pneumonia. If 
the eruption be tardy in its appearance, or indistinct, it is well to produce 
moderate counter-irritation by some gentle irritant underneath, as cam- 
phorated oil, to which one third part of turpentine is added. 

Affections which complicate measles should receive, for the most part, 
such treatment as is appropriate for them when idiopathic. Secondary 
diseases, however, require sustaining measures more than primary. In 
bronchial and pulmonary inflammations, which, if they occur early in 
measles, prevent the regular appearance of the eruption, or, if in the 
eruptive stage, cause its disappearance, prompt counter- irritation over the 
chest by sinapisms, or otherwise, is required. Trousseau states that he 
has derived benefit, in these cases, from what he designates urtication. 
This is produced by stroking the chest two or three times daily with the 
nettle (urtica dioica or urtica urens). This causes a prompt and abundant 
eruption, and with a less amount of suffering than one would suppose. 
The fever abates, and the respiration becomes more natural in proportion 
to the amount of nettlerash. On the second day the effect is less than on 



SCARLET FEVER. 187 

the first, and after three or four days, says Trousseau, no further irritation 
results from the nettle. When counter-irritation is produced, by what- 
ever method, the chest should be covered with a warm and soft poultice, 
as the ground flaxseed ; derivatives to the extremities are useful in such 
cases. In capillary bronchitis and pneumonia stimulating expectorants 
are required, as carbonate of ammonium. The following I employ for a 
child of two or three years. 

]J. Tinct ipecac, comp 

(Squibb's liq. Dover's pulv.), gtt. viij-xvj. 

Ammon. carbonat., gr. xvj~5ss. 

Syr. bal. tolut., 

Aquae, aa | j. Misce. 
One teaspoonful every 2 or 3 hours. 

Muriate of ammonium is also a good remedy in these cases, employed 
in double the dose of the carbonate. 

Quinia to reduce the fever, and digitalis as a heart tonic, are also very 
useful in these inflammations, given alone or alternately with the above. 

The cases of gangrenous vulvitis alluded to above were treated with a 
flaxseed poultice, and iodoform dusted over the surface each day or second 
day, with a satisfactory result. As regards the treatment of other com- 
plications, the appropriate measures are detailed elsewhere. 



CHAPTEE II 

SCARLET FEVER. 



The terms scarlet fever, scarlet rash, and scarlatina are identical. 
They are employed to designate one of the most frequent and fatal of the 
contagious diseases, a disease which may occur at any age, but is most 
common in childhood, an exanthem attended with more or less pharyn- 
gitis. In this city, on account of its great frequency, and its large per- 
centage of fatal cases, it causes more deaths than any other contagious 
malady. Though not more common than measles, it is attended, with 
us, by more than double its mortality. 

There is no disease that presents a greater difference as regards char- 
acter and severity of symptoms, than scarlet fever, and this has led to the 
recognition of different forms of it. Rilliet andBarthez describe two, the 
normal and abnormal ; Meigs two, the mild and grave ; and most other 
writers, three or more. I shall, for convenience, follow Bouchut, who 
makes three varieties, namely, the regular, irregular, and malignant. 



188 SCARLET FEVER. 

Symptoms. Regular Form. — Scarlet fever usually begins abruptly. 
It is possible, often, to tell the exact time of its commencement. If there 
be any premonitory symptoms, they are ordinarily slight, so as scarcely 
to attract attention, amounting to little more than dulness, or the appear- 
ance of fatigue. In some the first symptom is chilliness and occasionally 
a distinct chill is experienced. This is the ordinary mode of commence- 
ment in the adult. With or without the chilliness, fever, usually intense, 
arises, accompanied by such symptoms as ordinarily occur in a febrile 
state of system, such as cephalalgia, perhaps delirium, anorexia, thirst. 
The pulse rises to 110, 120, or more, per minute ; the skin is hot, face 
flushed, the eyes bright, and the temperature is 102° to 104°. In many, 
there is sudden starting or twitching, with a degree of stupor, showing 
that the cerebro-spinal system is profoundly affected. 

In most cases there occurs within the first twenty -four hours a symptom 
which has considerable diagnostic value, namely, vomiting. In 117 cases 
in which I have recorded its presence or absence, it occurred in 90, usually 
not at the very commencement, but within the first twelve or eighteen 
hours. It commonly occurred before the appearance of the rash, but not 
always. In a few of the cases it is recorded as a symptom of the second 
day. Vomiting at this period is, probably, in most cases, sympathetic, due 
to the irritating effect of the scarlatinous virus on the brain. It is not a 
severe symptom, occurring in most patients but once or twice. Great and 
persistent irritability of stomach indicates a serious form of scarlet fever, 
and is, therefore, prognostic of an unfavorable ending. When this symp- 
tom is absent or slight, or there is merely nausea, I have found the case 
ordinarily mild, so that, as regards the frequency of vomiting, the statis- 
tics of different epidemics vary according to the mildness or gravity of the 
type. The bowels are regular or somewhat constipated in this form of 
scarlet fever, or, if diarrhoea occur, it is slight and transient. 

When the symptoms described above have continued six to eighteen 
hours, the rash appears. It is first observed about the ears, neck, and 
shoulders, in reddish indistinct patches, fading into the normal hue. These 
patches extend and unite, and in the course of a few hours the trunk and 
upper extremities, and finally the legs, are covered. The scarlatinous rash 
bears considerable resemblance to that produced by external heat or the 
redness from a sinapism, but there are numerous minute points of a deeper 
or duskier red than the surface generally. On passing the finger over the 
eruption, no distinct prominences are observed, but a sensation of rough- 
ness is sometimes imparted from engorgement of the cutaneous papillae. 
The rash disappears by pressure, but in robust children, and in favorable 
cases, it immediately returns when the pressure is removed. Slow return 
of the rash is evidence of sluggish circulation, and, when marked, it indi- 
cates the malignant form of the disease. The rash gives rise to an itching 
or burning sensation, which adds greatly to the discomfort of the patient. 



SYMPTOMS. 189 

The degree of redness is not uniform over the surface, and sometimes, 
especially in mild cases, it is absent in places. 

Early in the disease, even before the cutaneous eruption, the buccal 
and faucial mucous membrane presents a pretty general red appearance, 
and the papillae of the tongue are elevated. Pharyngitis has already com- 
menced, with more or less stomatitis and tonsillitis. The inflammation 
renders deglutition painful, so that difficulty is often experienced in giving 
the necessary drinks. This state of the buccal and faucial membrane con- 
tinues through the disease. There is sometimes a slight fibrinous exuda- 
tion over the tonsils ; the tongue is covered with a moist fur, and the 
secretion from the follicles of the inflamed surface is increased and muco- 
purulent. The Schneiderian membrane also participates in the inflamma- 
tion, and, as the disease advances, a thin, irritating discharge, containing 
pus-cells, flows from the nostrils. 

The temperature in the first days of scarlet fever is ordinarily from 
102° to 105°, in grave cases even 105° to 107°. The cutaneous trans- 
piration during this period is nearly checked, so that the skin is hot and 
dry. The respiration is moderately accelerated, but not so as to attract 
attention, unless there be a complication ; often there is slight cough from 
mucus in the throat or bronchial tubes. Bronchitis, common in mea- 
sles, and giving rise to prominent symptoms in that disease, is either 
absent or slight in scarlet fever. 

The symptoms pertaining to the digestive system during the initial 
period of scarlet fever have been sufficiently described. The subsequent 
symptoms do not differ materially in regular scarlet fever, except that 
there is no vomiting. The lips are dry and often cracked. The inflam- 
mation of the mouth and throat continues unabated, with anorexia and 
thirst. The urine is high-colored, and in robust children, during the first 
days of scarlet fever, it frequently deposits the urates on cooling. 

The symptoms continue with undiminished intensity for a period of 
from four to six days, when the fever begins to abate, the pungent heat 
becomes less, and the rash fainter. There is a gradual decline of the 
disease, which, in its inception, was so abrupt. In mild, and even 
pretty severe cases, which pursue a regular and favorable course, conval- 
escence commences by the close of the first or beginning of the second 
week. In the second week, the rash, becoming less and less distinct, 
finally disappears, as do also the redness and swelling of the buccal and 
faucial surfaces. The engorgement of the papillae of the tongue and that 
of the tonsils subsides ; the appetite returns ; the countenance brightens 
and becomes natural, and the child who, during the height of the fever, 
scarcely noticed objects, or noticed them with indifference, or even re- 
pugnance, can be amused as before his sickness. 

The period of desquamation succeeds. Exfoliation of 'the epidermis 
occurs over the whole body. This commences about the face and neck, 



190 SCARLET FEVER. 

and it occupies several days, during which there is progressive improve- 
ment in the condition of the child. Where the skin is thin, the epi- 
dermis, as it is detached, presents a furfuraceous appearance ; where it 
is thick, as upon the palms of the hands and soles of the feet, it separates 
in a layer of considerable thickness. 

Such is a brief account of scarlet fever, when it pursues its normal 
course, without complication or sequelae. But there is no disease which 
has so many unfavorable complications and sequela? as this. The liabil- 
ity to these accidents renders the prognosis in all cases doubtful, and in 
many instances they are the immediate cause of death. They occur both 
in mild and severe cases of scarlet fever. 

The great difference in different cases of scarlet fever, as regards in- 
tensity of symptoms, is well known. It is sometimes so mild, its character- 
istic features so slight, that diagnosis is necessarily uncertain. Exam - 
pies in corroboration of this statement are not infrequent. In the spring 
of 1866 I was called to an infant thirteen months old, who had slight 
pharyngitis, and an indistinct rash over a part of the surface. In two 
days the eruption had disappeared, and soon after the health was appar- 
ently fully restored. Diagnosis would have remained doubtful, except 
for sequelae. In another instance, two children passed through the entire 
course of scarlet fever, playing every day in the street. Although the 
intelligent grandmother saw the rash upon them, its nature was not 
suspected till nearly two weeks afterward, when one was taken with 
fatal nephritis and general anasarca. In cases so mild as these, the heat 
of surface is not greatly increased, nor is the pulse much accelerated. 
There is no restlessness, nor is the digestive function materially impaired. 
The rash does not have so deep a color, nor is it so continuous over the 
surface, as in cases of ordinary gravity. The patient begins to improve 
in from two to four days, and is soon well. So mild a form of scarlet 
fever is, however, quite exceptional, but there are all varieties, from this 
mildness to that malignant form which I shall presently describe. 

There is usually considerable faucial inflammation, even when scarlet 
fever pursues a regular and favorable course. If the pharyngitis be intense 
and protracted, many writers designate the disease scarlatina anginosa. 
There is, in these cases, not only general and pretty severe inflammation 
of the mucous membrane of the fauces, with swelling of the tonsils, and 
submucous infiltration, but also more or less tumefaction around the angle 
of the jaw, due to extension of the inflammation to the lymphatic glands, 
and connective tissue of the neck. In these cases the suffering of the 
patient is greatly increased by the amount of local disease. The adenitis 
and cellulitis, unless slight, do not subside with the disappearance of the 
rash, or they subside more slowly. They render the febrile movement 
more protracted. The swelling due to these inflammations often con- 
tinues one or two weeks after the disappearance of the rash or even longer, 



SYMPTOMS. 191 

when it disappears by resolution, or frequently by suppuration, the ab- 
scess opening externally. 

Irregular Form. — The irregular form of scarlet fever is commonly due 
to some perturbating cause. This cause is often a pre-existing or coexist- 
ing disease, or, if not actual disease, at least disordered state of system. 
For example, a little girl, in my practice, had the symptoms of scarlet 
fever, such as febrile movement and inflammation of the buccal and fau- 
cial surfaces, nearly a week before the scarlatinous eruption appeared. 
During this period there were symptoms of enteritis, which declined when 
the rash occurred. The abdominal affection was the apparent cause of 
the irregularity in the malady. If scarlet fever occur during an attack of 
entero-colitis, there is frequently no eruption. Most practitioners have 
met cases like the following, which I now recall to mind : In a family where 
scarlet fever was prevailing, a little child, early after the commencement 
of symptoms which seemed to be plainly referable to the exanthematic 
affection, was seized with vomiting and purging, and the latter continued 
two or perhaps three days, when death occurred. There were the symp- 
toms and appearances of severe scarlet fever, but without the eruption. 
In another instance, an infant in the warm months, having protracted 
entero-colitis, the usual summer epidemic of this city, was apparently 
affected with scarlet fever, which was present in the family. There were 
the characteristic symptoms, but the diarrhcea continued and there was 
no rash. 

In those that are much reduced by any antecedent disease, as phthisis, 
or that have a disease, chronic or acute, which produces a decided afflux 
of blood toward an internal organ, the eruption is commonly tardy in its 
appearance, indistinct, or wholly absent. The diseases which most fre- 
quently render scarlet fever irregular are those of an inflammatory nature. 
Some affections, occurring in connection with scarlet fever, do not change 
its symptoms, but themselves undergo modification. Scarlet fever occur- 
ring in a child having pertussis does not itself undergo any material 
change. The cough, not the fever, is sometimes modified during the co- 
existence of the two. 

Scarlet fever may also be irregular in those that are robust and free 
from any other disease, assuming this form without any appreciable per- 
turbating cause. In 1867 I attended a young lady, whose previous health 
was excellent, and whose brother was sick at the time with scarlet fever. 
This patient had considerable fever, with pretty severe pharyngitis, and, 
though her surface was repeatedly examined, no eruption could be discov- 
ered. Two weeks subsequently she became affected with severe nephritis, 
anasarca, effusion into at least one of the pleural cavities, and probably 
into the pericardium, the case ending fatally. 

Rilliet and Barthez mention the irregular and incomplete cnaracter of 
the eruption in second attacks of scarlet fever, which, though uncommon, 



I9S4 SCARLET FEVER. 

are met from time to time. Scarlet fever, occurring a second time some- 
times presents all the features of the regular disease and pursues its nor- 
mal course, but it is much more apt to be incomplete and irregular than 
the first attack. It is more apt to be irregular if the interval between 
the two have been short than if several years have elapsed. 

Malignant Form. — This form of scarlet fever is in some epidemics 
common, while in others it is rare. It usually commences with severe 
symptoms, those pertaining to the nervous system predominating, such as 
intense cephalalgia, with delirium. Many pass rapidly into coma and die 
within two or three days. They succumb to the virulence of the scarla- 
tinous poison, while the disease is still in its commencement. The rash in 
malignant scarlet fever is dusky. It disappears by pressure, and returns 
slowly when the pressure is removed. There is, therefore, extreme slug- 
gishness of the capillary circulation. In some there is great restlessness. 
If placed in one position on the bed they soon throw themselves, in a 
half-conscious or unconscious state, into another. They do not speak at 
all, or they mutter like those affected by the graver forms of typhus, call- 
ing the names of playmates, or talking about things which interested them 
when well. There is great elevation of temperature, the thermometer, 
placed in the axilla, rising above 103° to 105°, even to 107°, and the heat 
of surface is pungent, except when the case approaches a fatal termination. 
The pulse from the first is rapid, numbering from 130 to 160 per minute. 
Sometimes there is great heat of head and body, while the limbs are 
cool. This is an unfavorable sign. 

Severe and dangerous nervous symptoms, as convulsions and coma, 
occur chiefly within the first three or four days. After this period the 
danger is mainly from exhaustion. Those who survive the onset of the 
disease, often have, in the course of a few days, severe pharyngitis, with 
inflammation of the lymphatic glands, and connective tissue around the 
angle of the jaw, accompanied by external swelling. The pharyngitis is 
attended by more or less secretion of mucus or muco-pus, which, some- 
times collecting around the entrance of the larynx, causes noisy respira- 
tion, or even, if the system be greatly prostrated, embarrasses respiration 
by entering the larynx. The chief danger, however, from the pharyngitis, 
is due to the exhaustion which it causes. By rendering deglutition diffi- 
cult, it interferes seriously with nutrition. 

Complications. — Complications may occur in any form of scarlet 
fever, but they are most frequent in malignant or grave cases. The most 
common and serious complication, as regards the nervous system, is clonic 
convulsions. These occasionally occur at the commencement of the dis- 
ease, before the appearance of the rash, and many then recover, but I 
have not seen, nor have I heard, in my intercourse with physicians, of 
any case which recovered when convulsions occurred after the complete 
development of the eruption. On the other hand, some of the physicians 



COMPLICATIONS. 193 

of this city, of largest experience, inform me that they consider convul- 
sions during the eruptive stage an almost certain precursor of death. 
Convulsive attacks in scarlatina are probably due, in part, to congestion 
of the nervous centres, for we sometimes find, in young children, at the 
time of the seizure, and immediately before it, the anterior fontanelle pro- 
minent, and forcibly pulsating. The convulsions uniformly increase the 
congestion, but, as the latter antedates the former, its causative relation 
seems to be established. But the most important element in the causation 
of convulsions in scarlet fever is, probably, the presence in the blood of 
the scarlatinous virus. This, whatever its exact nature, may, in my 
opinion, cause convulsions, with or without the co-operating influence of 
congestion, as urea gives rise to them in cases of uraemia. Convulsions 
occurring at the commencement of scarlet fever are usually single. If 
repeated,* they become more serious. Convulsions after the appearance of 
the eruption, either end at once in coma, or they return at short intervals, 
with gradually increasing drowsiness, till coma supervenes. 

The anginose affection in scarlet fever may be so severe, or assume such 
features, as to constitute a complication. It may become more serious 
than the primary disease itself, so as to require the chief treatment. 
Within the last few years diphtheria has so frequently complicated scarlet 
fever, that physicians have learned to make daily examinations of the 
fauces till convalescence is fully established. So common is this compli- 
cation, that scarlet fever has been justly regarded as affording conditions 
which are especially favorable for the development of diphtheria. Diph- 
theria may occur early in scarlet fever, or not till the latter begins to 
decline, when it produces sudden aggravation of symptoms, and renders 
the case, which before was perhaps favorable, one of great gravity. As 
has been stated elsewhere, a pseudo-membranous formation upon the fau- 
cial surface, especially over the tonsils, is not uncommon in severe anginose 
scarlet fever, but is soft or pultaceous, in isolated points or patches, and 
easily detached. On the other hand, in the cases to which I have alluded, 
of diphtheritic complication, the pseudo-membrane is firm and thick, pene- 
trating the mucous membrane so as to produce bleeding when forcibly 
detached, as in primary diphtheria. Besides affecting the fauces, the 
diphtheritic inflammation is very apt to attack the nostrils, causing swell- 
ing and exudation, so as often to embarrass respiration. This complica- 
tion obviously greatly increases the severity of the case. It intensifies 
the febrile movement, and renders it more protracted. It produces or 
increases the adenitis and cellulitis around the angle of the jaw, causing 
within a few days, if unchecked, such tenderness and swelling of these 
parts as to render movements of the jaw and deglutition painful. 

An occasional result of severe pharyngitis in scarlet fever is suppuration, 
or gangrene, occurring in the subcutaneous connective tissue of the neck. 
Whether suppuration occur, and an abscess form, or gangrene result this 



194 SCARLET FEVER. 

complication is often serious. Suppuration or gangrene indicates an in- 
tense grade of inflammation or a low vitality ; but many with this com- 
plication recover through a protracted convalescence. 

If suppuration be extensive, it may so increase the debility that death 
occurs in consequence. Gangrene is a more serious complication ; unless 
slight, it renders a fatal termination highly probable. The connective 
tissue, subcutaneous or intermuscular, is the part which primarily sloughs. 
The skin over the gangrene becomes brown or dark, and separates with the 
slough. In the majority of cases the slough is not large. Exception- 
ally it extends so deeply that, when it separates, the muscles and even 
vessels of the neck are laid bare, and the appearance is revolting. In a 
case of this sort, which I saw a few years since in the practice of 
another physician, the cavity, after the slough had separated, was irregu- 
lar, and sufficiently large to admit a hen's egg. It extended a consid- 
erable distance out of sight under the skin, and finally opened a vessel 
from which fatal haemorrhage occurred. 

Gangrene of the mouth also occurs in rare instances, either as a com- 
plication or sequel. I have met it in two cases, one of which recovered. 
In the fatal case it began while the patient was still under treatment for 
the fever, and was first discovered by the loss of two incisors. The one 
that recovered also lost two incisors, and a part of the superior maxillary 
bone. The one that died was scrofulous, but under good hygienic condi- 
tions ; the other lived in a tenement-house, and was ill-cared for. Rilliet and 
Barthez relate three cases of gangrene of the mouth, occurring, however, 
not as a complication, but sequel, of scarlet fever. One of these patients 
had, within eighteen days, varioloid, scarlet fever, and measles ; these 
diseases ending in fatal gangrene of the pharynx and cheek. The second 
child was taken, on the seventeenth day after the commencement of scar- 
let fever, with gangrene of the pharynx, succeeded by that of the cheek, 
and died on the twenty-fourth day. In the third case the gangrene was 
preceded by smallpox as well as scarlatina. Other observers have re- 
corded similar cases. 

Another complication, to which allusion has already been made, is entero- 
colitis. This may antedate the scarlet fever. In other cases, entero- 
colitis commences either with the scarlet fever, or during its course. 
Diarrhoea often occurs in connection with the vomiting, in the first hours 
of the fever ; and it commonly ceases during the first or second day. 
Occasionally it continues with greater or less severity, when it constitutes 
a serious complication ; it is in these cases due to intestinal inflammation. 
Bronchitis and pneumonia, so common in measles, do not often compli- 
cate scarlet fever. 

A not infrequent complication is articular rheumatism, occurring when 
the fever begins to decline. Mild cases are more liable to it than those 
of a severe form. Attention is called to it by the complaint of the 






COMPLICATIONS. 195 

child of pain or tenderness in the affected joints ; or, if he be too young to 
speak, by evidences of pain when the joints are pressed or moved. There 
are usually but little swelling and redness, and there are fewer joints 
affected than in most cases of acute primary rheumatism. In my practice, 
a common seat of scarlatinous rheumatism has been the areolar tissue of 
the wrist. The inflammation and infiltration are less than in primary 
acute rheumatism. This complication is not, ordinarily, serious ; nor does 
it, as a rule, materially retard convalescence. A physician of this city, 
however, informs me of two cases in which cardiac inflammation occurred 
in connection with the articular affection, as it frequently does in idio- 
pathic rheumatism, and I have attended one case in which the same 
complication occurred with permanent crippling of the mitral valves. The 
urates are not so commonly present in the urine in scarlatinous as in or- 
dinary acute rheumatism. 

Serous inflammation, especially that affecting the peritoneum, pleura, 
or pericardium, is a common complication, independently of the rheumatic 
affection. It occurs during the desquamative period, and, continuing 
afterward, becomes a sequel. Many such cases are fatal. Pericarditis 
may be with difficulty diagnosticated, if it be slight, and attended by only 
a moderate amount of effusion, and it is, doubtless, sometimes the cause of 
death in those who die suddenly and unexpectedly during or soon after an 
attack of scarlet fever. The pleuritis is often suppurative (empyema), usually 
requiring thoracentesis for its cure, but recovery by ulceration is possible. 
Thus in 1865 I attended a little girl in a mild attack of the fever, and 
when the case was about being discharged, severe pleurisy began on the 
right side. The pleural cavity was soon half filled with liquid, and after 
a sickness of two months, this liquid, mainly pus, communicated with a 
bronchial tube, and was expectorated. She immediately began to improve. 
At present, with our excellent instruments, this case would have been 
treated by thoracentesis. 

In the following case, the records of which are from my note-book, 
pericardial and peritoneal inflammation occurred as a complication of 
scarlet fever : 

Case. — April 7th, 1860, C , girl, five years and ten months old, had 

measles two years, and whooping-cough one year ago. With the exception 
of a slight cough, she has since remained well, till the present sickness. 
Scarlatina commenced April 4th, and on the 5th the eruption appeared. 
Symptoms severe, but regular ; pulse 158, full ; surface hot, and covered 
with the eruption ; delirium at night ; stomach irritable ; constipation. 
April 8th to 10th, symptoms about the same ; no delirium, however; pulse 
varying from 124 to 153 per minute ; a deposit of urates in the urine. 

11th. To-day, for the first, has severe pain in the epigastrium, accom- 
panied by tenderness on pressure, and moderate distension at this point. 
The symptoms otherwise are favorable, though pretty severe ; pulse 140 ; 
respiration moderately accelerated, but the rhythm natural ; respiratory 
murmur distinctly heard in all parts of the chest, vesicular in character, 



196 SCARLET FEVER. 

and without rales. Has taken till to-day mainly diaphoretic mixtures ; 
to-day pulv. ipecac, comp., gr. iij., every three or four hours, is ordered ; a 
flaxseed poultice to be applied to the epigastrium ; diet nutritious, with 
moderate use of stimulants. 

12th. Epigastric pain still severe ; great tenderness on pressure ; con- 
siderable distension at this point, and percussion elicits a dull sound ; 
passed a restless night ; when asked where she feels pain, she points to the 
throat and epigastric region ; pulse 130 to 140 per minute ; rash fading ; 
surface warm ; bowels somewhat relaxed ; urine passed in usual quantity. 
The treatment by Dover's powder and poultices is continued, and a leech 
is to-day applied to the epigastrium. 

\?>th. Pain less severe, but considerable tenderness on pressure ; pulse 
about the same as yesterday ; has had through her sickness a slight cough. 
She talks rationally, and sits much of the time in bed. 

. l^th. Continued in the same state as described in yesterday's records, 
till 3 P.M. yesterday, when she became suddenly worse ; her respiration 
was short and gasping ; she spoke, with an effort, in a whisper, but con- 
tinued conscious ; and her pulse was strong. Death occurred at 5 P.M., 
apparently from obstructed respiration. In the last days of her sickness 
there was but little pharyngitis, and little or no external swelling. 

Autopsy twenty-four hours after deatK. — Body a little emaciated ; 
heart large for a child of five years ; about one ounce of turbid serum in 
the pericardium ; a soft deposit of lymph within the pericardial sac at the 
base of the heart around the origin of the great vessels, an evidence of 
recent circumscribed pericarditis ; from four to eight ounces of transparent 
serum in each pleural cavity ; no fibrin upon or opacity of the pleural sur- 
faces ; mucous membrane of bronchial tubes injected in streaks, and muco- 
pus can be pressed from them ; both lungs can be readily inflated, with 
the exception of small portions of both the lower lobes, which are hepa- 
tized, and can be but partially inflated ; liver enlarged, presenting a con- 
gested appearance, and extending some four inches below the free border 
of the ribs ; upon its convex surface in the epigastrium, corresponding 
with the seat of the pain, is a white, rough patch of fibrin, about one and 
a half inches in diameter ; kidneys congested ; stomach and small intes- 
tines apparently healthy ; mesenteric glands moderately enlarged ; mu- 
cous membrane of transverse and descending colon somewhat injected and 
thickened, showing mild colitis ; no ulceration noticed ; brain not exam- 
ined 

Microscopic examination was made of the blood, hepatized portions of 
lung, etc., but nothing of special interest in this connection was observed. 

This case is instructive as showing the liability which exists in and 
after scarlet fever to serous inflammations, and the difficulty of diagnosti- 
cating them in certain cases on account of their circumscribed character. 

Sequelae. — The complications described above may occur as sequelae, 
but there is another pathological state which may be a complication, and 
is a common and serious sequel. I refer to nephritis with albuminuria. 
This occasionally commences in scarlet fever, but usually not till the dis- 
appearance of the rash. There is sometimes, during the course of scarlet 
fever, and even subsequently, slight albuminuria due to simple congestion 
of the kidneys, but the albuminuria to which I allude, and which requires 



SEQUELS. 197 

treatment, is more serious. Its anatomical character is as follows : Hy- 
peremia, and perceptible increase in volume of the kidneys ; prolifera- 
tion of the renal epithelial cells like that of the epidermis, and a granular 
deposit in them ; the escape of albumen from the engorged capillaries, 
and its appearance in the urine ; the formation of hyaline or granular casts 
or both, in the tubuli uriniferi, these casts often containing epithelial cells ; 
the escape of the casts from the kidneys with the urine ; diminution of 
amount of urea excreted, and, therefore, its accumulation in the blood ; 
and, finally, rupture of the engorged capillaries of the kidneys, and min- 
gling of the elements of the blood with the urine. 

The presence, therefore, of this renal affection can be readily ascertained 
by examining the urine. The quantity of albumen which this liquid 
contains can be approximately ascertained by adding nitric acid or apply- 
ing heat. If the quantity be small, simple cloudiness is produced; if large, 
the urine becomes thick and white, and in extreme cases almost semi-solid 
from coagulation of the albumen. The character of the urine can, how- 
ever, be more accurately ascertained by the microscope than by the tests 
which have been mentioned, since by it we discover the casts, altered 
epithelial cells, and blood-corpuscles. 

Nephritis, with the consequent uraemia, soon gives rise to evident symp- 
toms. Serous effasion takes place in consequence of the altered state of 
the blood, the most common form of which is anasarca, occurring upon 
the face and limbs, and sometimes in the connective tissue of the trunk. 
Often the effusion occurs only in the external connective tissue, and the 
result may then be favorable ; but in other cases it occurs, and in the order 
mentioned as regards frequency, in the lungs (oedema pulmonum), serous 
cavities, and, lastly, in the submucous connective tissue of the larynx 
(oedema glottidis). Obviously the danger in itself from this escape of 
serum depends on its location, but, whenever and wherever observed, it 
indicates the beginning of an unpleasant sequel, and the urine should be 
carefully examined, in order to ascertain the gravity of the renal disease, 
from the amount of albumen and casts. 

Scarlatinous nephritis, with consequent uraemia, is due to the direct 
effect of the scarlatinous poison on the kidneys. I have known it occur 
in the nurse who attended a child through the fever, but did not suffer 
from the fever herself. It sometimes begins quite abruptly, and often 
when the patient has been progressively convalescing, and, perhaps, has 
seemed out of danger. In most cases, however, there are well-marked 
premonitory symptoms, as fever, restlessness, and loss of appetite. The 
anasarca is first observed in the face or about the ankles. Sometimes it 
remains inconsiderable, but in other cases it increases day by day, more 
or less rapidly, till the appearance of the patient is much altered. In 
marked cases of anasarca the features are so bloated that their natural 
expression is lost. The volume of the trunk and legs is augmented, and 



198 SCARLET FEVER. 

more slowly, that of the arms. In the male child the penis and scrotum 
frequently attain three or four times their normal dimensions, in conse- 
quence of serous infiltration. 

The duration of the anasarca or dropsy is very different in different 
cases. If the form be oedema pulmonum, oedema glottidis, or intracranial 
effusion, death is speedy. It may occur even within a day. Hydrothorax 
and hydropericardium are also ordinarily fatal, though not so speedily ; 
while in ascites the prognosis is much more favorable. The duration of 
anasarca under the most favorable circumstances, unless it be very slight, 
is commonly not less than two or three weeks, and is often much longer. 
But the chief danger in a majority of these cases proceeds not from the 
dropsies, but from the poisonous effect of the retained urea on the nervous 
centres, so that in grave cases, nervous symptoms are common, as in 
Bright' s disease of the adult. Headache, convulsions, and coma are apt 
to succeed the scanty flow of urine, and ursemic vomiting in fatal cases, 
even when the amount of serous effusion is moderate. 

The liability to this renal malady is greatly increased, and in some 
cases is mainly attributable to the close relationship, as regards their func- 
tions, which exists between the skin and kidneys. A common exciting 
cause is exposure to vicissitudes of temperature or currents of air, by which 
the surface is chilled, and cutaneous transpiration checked, at the time 
when the old epidermis is being detached. The increased burden thrown 
upon the kidneys results in the pathological state which has been described. 
This remark does not conflict with the statement already made, that the 
nephritis is due to the direct effect of the scarlatinous principle on the 
kidneys, the disturbance of the function of the skin merely increasing the 
functional activity of these organs and rendering them more susceptible to 
the disease. All who have seen much of scarlet fever can recall to mind 
cases in which the patients had nearly recovered, when from some needless 
exposure in the streets, or by chilling of the body in a cold room, or open 
window, this affection occurred, with perhaps a fatal result. Elsewhere I 
have alluded to a case in which scarlet fever was only detected by this 
sequel, which began when the child was daily exposed in the open air. 
But many children who have been attended with the utmost care, and 
who, through the whole desquamative period, are kept in a uniform tem- 
perature, nevertheless become affected with albuminuria and dropsy, so 
that there is sufficient cause of this sequel in the state of the child and the 
nature of the disease through which he has passed, apart from extraneous 
influences. It is an interesting fact that albuminuria seems more apt to 
occur after mild than severe cases of scarlet fever, and observations appear 
to show that this difference in liability to nephritis is intrinsic ; in other 
words, that it does not depend, as some have supposed, on a difference in 
the hygienic management of mild and severe scarlatina, but in the nature 
of the disease itself. 



SEQUELS. 199 

The symptoms in scarlatinous nephritis vary not only according to the 
degree of the inflammation, but also according to the amount and seat of 
the effusion. I have stated that it usually commences with languor and 
more or less fever. The pulse remains accelerated, the skin is hot and 
dry, and the appetite poor. This affection, if slight, may occur without 
appreciable effusion, either in the connective tissue or the cavities, but 
ordinarily in these mild cases a little puffiness is observed around the eyes 
or upon the extremities. In the majority of cases more extensive anasarca 
results. The skin is then pallid, distended, and pitting on pressure. The 
anasarca does not, in most instances, give rise to any marked symptoms. 
If oedema glottidis or pulmonum occur, the respiration becomes rapidly 
more embarrassed, till soon the blood is no longer sufficiently oxygenated 
for the purposes of life. The chief symptom in hydrothorax is accelerated 
and difficult respiration ; in hydropericardium the symptoms are such as 
arise from embarrassed action of the heart ; in ascites there are either no 
marked symptoms, or, if the amount of liquid be large, there may be more 
or less embarrassment of respiration from compression of the lungs. 

Otitis. — Too little attention has unquestionably been given to the state 
of the ear in scarlet fever, and yet the middle ear, lined like the nostrils 
and fauces by a mucous membrane, and in direct continuity with the 
fauces, through the Eustachian tube, is often the seat of an inflammation 
which, if neglected, involves serious ulterior consequences. This inflam- 
mation commonly commences, or becomes so pronounced as to cause symp- 
toms, in the declining stage of scarlet fever, or during convalescence. The 
history of the patient is somewhat as follows : The scarlet fever has prob- 
ably pursued a normal course ; the naso-pharyngeal surface has been for 
some days inflamed, and the redness may be declining, when the child 
begins to complain of earache. The delicate mucous membrane lining the 
Eustachian tube and middle ear is injected and swollen, and the tube be- 
comes impervious by the swelling, so that the tympanum is no longer an 
open, but a closed cavity. The serum, mucus, and pus produced from the 
inflamed tympanic surface, therefore, unable to flow away, collect, and by 
their presence and pressure cause the severe throbbing and aching which 
attend this disease. The effusion, at first largely serous, becomes more 
and more purulent, and, as the quantity increases, the drum is pressed 
outward, the mastoid cells become filled and tender to the touch, and often 
the collateral oedema causes tumefaction and narrowing of the external ear. 
After a variable time, perhaps two or three days, or not till after a week 
of suffering, the drum becomes thinner at one point from ulceration and 
bursts, and the imprisoned secretions escape into the external ear. If this 
terminated the history, it were well ; but, unfortunately, while in a certain 
proportion of cases the aperture in the drum heals kindly, and the inflam- 
mation abates without impairment of hearing or permanent injury of the 
auditory apparatus, there is in a large proportion of cases a subsequent 



200 SCARLET FEVER. 

unpleasant history. The mucous membrane which lines the bony walls of 
the middle ear has the function of a periosteum, and, therefore, when 
intensely inflamed, and subject to pressure, is liable to ulcerate. As in 
other parts of the skeleton under similar conditions, superficial caries or 
necrosis of the underlying bone is apt to occur. The delicate chain of 
small bones stretching backward from the drum may be irreparably 
damaged, the aperture in the drum may be so large that it never heals, 
and the ossicles, becoming detached, may be lost in the discharge. Cases 
are not rare in which one ear has received this extent of injury, but fortu- 
nately the hearing is seldom totally destroyed in both ears. I now recol- 
lect only one such case, although I have met many whose hearing was 
greatly impaired on both sides, indeed nearly lost. The carious or ne- 
crotic process may extend to the mastoid cells. An offensive otorrhoea 
continuing for months or years indicates the persistence of the inflamma- 
tory process within the ear, which is often rendered so obstinate by the 
presence of dead bone. 

But a more melancholy result is yet in store for certain cases. The 
tympanum is, in a certain part of its extent, separated from the meninges 
of the brain by only a thin layer of bone. The otorrhcea, after months or 
years, suddenly ceases, the child complains of constant severe headache, 
and is feverish, and in a few days death closes the scene in convulsions or 
coma. Fatal meningitis has supervened, produced by extension of inflam- 
mation from the bony wall of the tympanum. Strumous children are 
more liable than others to these serious sequelae of scarlet fever, which 
originate in or proceed from the internal ear. 

Anatomical Characters. — There is some difficulty in determining 
what are the anatomical characters of scarlet fever, since so many who 
die of this disease have a complication, and the lesions of this are super- 
added to those of the fever. The following, however, are the facts which 
have been ascertained in reference to this point. In many the brain, its 
membranes, and the lungs are congested ; often, also, the Peyerian, soli- 
tary, and mesenteric glands are enlarged, and the spleen enlarged and 
softened. The liver and kidneys do not present any notable alteration, 
though the latter are so often affected during the period of convalescence. 
Dr. Samuel Fenwick (London Lancet, July 23d, 1864) has made post- 
mortem examinations in sixteen cases of scarlet fever, and concludes from 
them that there is inflammation of the mucous membrane of the stomach 
and intestines like that of the skin, and that there is desquamation of the 
epithelial cells from these portions of the digestive tube like that of the 
epidermis. I have had opportunity of examining the stomach and intes- 
tines in a few instances in those who died in the eruptive stage, in the 
Nursery and Child's Hospital, and did not find any unusual hypersemia 
of the gastro-intestinal surface, unless when gastro-intestinal inflammation 
had occurred as a complication. In malignant cases, in which the 



ANATOMICAL CHARACTERS. 201 

cardiac systole is feeble in the last hours of life, ante-mortem coagulation 
of fibrin frequently occurs in the cavities of the heart, obstructing the cir- 
culation, and being the immediate cause of death. These clots are large 
and whitish, or yellowish- white. 

Nature. — Scarlet fever presents in a marked degree the distinguish- 
ing features of the infectious maladies. It is highly contagious, and is 
inoculable. Stoll, d'Amboise, and others successfully inoculated with the 
scarlatinous virus, using the blood, but without diminishing the intensity 
of the disease. Whether scarlatina ever originates spontaneously is un- 
certain ; but if it do so, such cases are rare. It is disseminated by exposure 
to patients or to fomites, but the distance to which it is contagious is 
short, probably not more than two or three yards. Some consider the 
distance to be even less than one yard. Knowledge of this fact is impor- 
tant, as by isolating in a family a child attacked by scarlet fever, and 
allowing no communication with the nurse, the other children often es- 
cape. A very common mode of communication is by clothing, so that a 
third person is the medium of transmission. I have noticed that when 
scarlet fever, as well as measles, is epidemic in this city, a large propor- 
tion of the cases, nearly all, indeed, of the first cases, can be traced to the 
public schools. Exposure occurs through those children who come from 
apartments where cases are under treatment. Physicians, and especially 
nurses, are sometimes the medium of communication. A medical friend 
of mine went directly from some children with scarlet fever, whom he was 
attending, to another family, where he took a little girl upon his knee. 
This girl in a few days became affected with scarlet fever and died. The 
two remaining children in the family were then attacked, and one died. 
Murchison alludes to similar cases (London Lancet, August 13, 1864). 
In one instance in my practice scarlet fever was communicated to an 
infant by a washerwoman whose own child had the disease, and who, on 
reaching the house where she had been engaged to work, threw her shawl 
over the cradle where the infant was sleeping. Six days later the infant 
was attacked. Mason Good cites a case in which a box of toys was the 
medium of communication ; and it is said that even a letter has been. 
The scarlatinous virus may remain for weeks and even months in apart- 
ments, clothing, or in or upon the person of one who has been affected, 
without any appreciable diminution in its effectiveness. A physician of 
this city, in whose family scarlet fever occurred, excluded a child from 
the room occupied by the patients, and from the patients themselves, for 
a month after the last case occurred, and yet although precautions had 
been taken in reference to clothes and bedding, this child was taken with 
scarlet fever soon after it was allowed to mingle with the other children. 
The father believes that the exposure was through the otorrhoea of one of 
the children. Observations, indeed, appear fully to establish the fact that 
the discharge from the ear or nostrils, and the particles of epidermis 



202 SCARLET FEVER. 

which have exfoliated, may retain the virus and be the medium of com- 
municating the malady several weeks after the fever has terminated. In 
a case in my practice a little girl returned home six weeks after her 
brother had scarlet fever, and, within a few days, took the disease. A 
more striking example occurred in the practice of Dr. Kearney Rogers, 
formerly a prominent and much-esteemed surgeon of this city, and was re- 
lated to me by an intelligent friend of the family since the doctor's death. 
Six children in a family had scarlet fever. Three and a half months sub- 
sequently another child, living at a distance, was allowed to visit them in 
the apartments where they had been sick. One week from that day this 
child also sickened with the same malady. Dr. Elliotson states that a pa- 
tient with scarlet fever was admitted into one of the wards of St. Thomas's 
Hospital, and, for two years subsequently, young persons who were 
admitted into this ward were apt to take the disease. Dr. Richardson 
relates the case of a family of four children, residing in the country. One 
died of malignant scarlet fever, and the rest, who had been removed, es- 
caped. Some weeks subsequently one of the children returned, but within 
twenty-four hours took scarlet fever and died. The cottage was now tho- 
roughly cleaned, whitewashed, and the clothing destroyed. Four months 
then elapsed, when the third child returned home, who also took scarlet 
fever in a malignant form and died. It was believed that the virus re- 
mained attached to the thatch, which extended close to the children's bed. 
Other similar examples might be mentioned, sufficient to establish the 
fact of the great permanence of the scarlatinous virus. 

The period of incubation in scarlet fever varies. It is seen in the re- 
markable example of contagion, given above, that it was only twenty- 
four hours. Trousseau also relates an interesting example of short incuba- 
tion. ' ' An English gentleman with his daughter was returning from Pau 
to London, and was joined at Paris by another daughter, who came direct 
from London. Scarlet fever was prevalent in London, but there was not 
a case of it at Pau. The second daughter was seized with scarlet fever in 
crossing the Channel, and joined her relatives in Paris seven or eight hours 
later. She occupied the same room in the hotel as her sister, who was also 
attacked within twenty-four hours. ' ' The incubative period is, however, 
seldom so short. It is usually from three to eight days. I might cite 
several cases in which this was its duration. Some writers allude to cases 
in which two, three, or even four weeks elapsed from the time of exposure 
to the appearance of the disease. It is, however, a question whether in 
such cases there may not have been a second and more recent exposure. 
Rostan alludes to cases in which scarlet fever was communicated by inocu- 
lation, and in which the period of incubation was seven days. 

Scarlet fever occurs most frequently between the ages of three and ten 
years. It is infrequent under the age of one year, and infants under the 
age of three months may be considered safe from an attack of it, though 



DIAGNOSIS. 203 

fully exposed. Cases have been reported of scarlet fever occurring in the 
foetus, and manifesting itself by the usual signs at birth. But a clear 
diagnosis in such instances is necessarily difficult, on account of the char- 
acter of the scarlatinous eruption on the one hand, and the nature of the 
cutaneous circulation in the newly born on the other. It is probable 
that, in the cases alluded to, there was an error of diagnosis. Certainly in 
two instances I have known women immediately after their confinement 
(within a week) take scarlet fever, and although they communicated the 
disease to others, did not to their infants ; and Murchison states that he 
has also twice observed similar cases. 

Most adults possess immunity from scarlet fever, although not protected 
by an attack of it in childhood. Parturient women, however, as we have 
stated, are liable to it, and there is considerable danger that the physicians 
who attend them, if at the same time visiting cases of scarlet fever, may 
communicate it to them. 

Scarlet fever is sometimes sporadic, but, as we meet it in this country, 
it occurs most frequently as an epidemic. The epidemics vary greatly in 
type. Some are mild, and attended by few complications, so that the re- 
sult of treatment is eminently satisfactory. In other epidemics the type is 
malignant, the complications frequent, and the percentage of deaths large. 
There is sometimes a succession of epidemics of one type, and then the 
character of the disease changes. This fact of a variable type is important 
as regards the value of statistics relating to treatment. Each epidemic has 
its prevailing character, but when the form is mild, there is now and then 
a case of severity, and when it is malignant, now and then one of unusual 
mildness. The epidemic influence is sometimes manifested in those ex- 
posed to scarlet fever by the occurrence of pharyngitis, and, as we have 
seen, nephritis. Professor George B. Wood, of Philadelphia, says 
{Treatise on the Practice of Med.) : " I seldom attend cases of scarlet 
fever without having sore throat." 

Scarlatina usually occurs but once in the same individual, but a second 
attack after the lapse of several years is not uncommon, and there are 
even cases of a third attack, one of which I have witnessed. But phy- 
sicians sometimes mistake roseola or erythema for scarlet fever, and, 
though afterward aware of their mistake, do not correct their diagnosis. 
Hence there is a belief in the community that second attacks are more 
frequent than they really are. 

Diagnosis. — In the commencement of scarlet fever, prior to the erup- 
tion, there are no symptoms or appearances which will enable us to make 
a positive diagnosis. Positive statement in reference to the nature of the 
disease might better be deferred, for the credit of the physician. Still, if 
a child with regular bowels, and no appreciable local disease, a few days 
after exposure to scarlet fever, be suddenly seized with intense fever, the 
pulse rising to 110, 120, or more, and the temperature to 102°, 103°, or 



204 SCARLET FEVER. 

105°, there is little doubt that the disease is scarlet fever. The diagnosis 
is rendered more certain if there be vomiting, and especially if, as is usual, 
there be redness of the fauces at this early period. 

When the eruption has appeared, the nature of the malady is, in most 
cases, apparent. Still, roseola or erythema, due to intestinal derangement 
or other causes, has often, as already stated, been mistaken for scarlet 
fever. A day or two suffices to show the error. In scarlet fever there is 
more inflammation of the faucial and buccal surfaces, more continuous and 
persistent redness of the skin, and greater intensity and persistence of 
symptoms, than in those diseases. Scarlet fever is also further distin- 
guished from them by the papular elevations upon the tongue, and the 
minute papula? upon the skin. Besides, in scarlet fever, except in the 
mildest cases, there is from the first the aspect of serious sickness, which 
roseola and erythema do not present. 

Scarlet fever and measles were long considered identical by the profes- 
sion, and, though the ordinary forms of the two diseases can be readily 
distinguished from each other, there are instances in which the differential 
diagnosis is attended by some difficulty. Measles occurring in a robust 
child, with an active cutaneous circulation, sometimes presents a continuous 
eruption over a considerable part of the surface, like the eruption of scar- 
let fever. But the longer period of invasion, the coryza and bronchitis, 
and the absence or slight degree of pharyngitis, in connection with other 
symptoms, enable us to distinguish these cases from scarlatina. Moreover, 
in those cases of measles in which there is continuous redness of surface 
where the circulation is most active, as upon the face, the characteristic 
rubeolous eruption is present in other parts, so that, with care in examina- 
tion, error of diagnosis may be avoided. Scarlet fever and measles may 
indeed occur together, but such a complication is rare. The diagnosis 
from rotheln will be considered when we treat of that disease. 

The greatest difficulty of diagnosis occurs in abnormal scarlatina, espe- 
cially when the rash is partial and indistinct. There is apt to be, in this 
form of the disease, an inflammatory complication, which causes with- 
drawal of blood from the surface, and it is sometimes very puzzling to de- 
cide whether this is a complication, or the sole disease. The points in- 
volved in diagnosis are numerous, but they are sometimes not sufficient 
to show the character of the affection. Generally, however, by observ- 
ing the clinical history from day to day, the diagnosis is established. In 
cases of doubt it is safest to adopt such hygienic management as is ap- 
propriate for scarlet fever. 

Prognosis. — The prognosis depends on the form of scarlet fever, 
whether mild or severe, the presence or absence of complications, and 
the strength of the patient. The mortality varies greatly in different epi- 
demics, in those of a mild form not being more than one in twelve or 
twenty, and the ratio may be less ; while, in those of a severe form, not 






PROGNOSIS. 205 

more than one recovers in every two, three, or four. The hospital statis- 
tics of Rilliet and Barthez show forty-six deaths in eighty-seven cases, 
while in some of the mild epidemics in the New York institutions the 
mortality has not been more than one or two per cent. Scarlet fever, 
like measles, is liable to sudden changes, either from complications which 
may arise or other causes, so that a case which gives a favorable promise 
in its commencement may, in a few days, present alarming symptoms. 
While in measles death nearly always occurs from a complication, in 
scarlet fever not a few perish from the direct toxic effect of the scarlati- 
nous poison, and not a few also from complications or sequelae. 

If the symptoms be mild, the temperature not exceeding 104°, with 
little or no delirium or drowsiness, and the efflorescence full, and appear- 
ing at the usual time, we may confidently predict recovery. Neverthe- 
less, nephritis, which is one of the gravest sequelae, is so apt to occur 
after the mildest cases, that families should always be warned of the dan- 
ger, that they may avoid needless exposure at the time of the decline of 
the fever and during desquamation. 

The symptoms which indicate an unfavorable ending are convulsions, 
except at the very commencement, great drowsiness with jactitation, a 
temperature exceeding 104° and especially 105°, rapid pulse, duskiness 
of the eruption, feeble capillary circulation, persistent vomiting, and 
diarrhoea. At a later period, particularly at the close of the first or in 
the second week, other unfavorable symptoms may occur in severe cases. 
The inflammation of the fauces is often so violent that it extends to the 
neighboring glands and connective tissue, producing severe adenitis and 
cellulitis. These inflammations, in proportion to their severity, increase 
and protract the fever, interfere with the proper use of nutriments, and, as 
they are apt to end in suppuration and sometimes in sloughing, they retard 
convalescence, and render recovery more doubtful. 

As dangerous complications and sequela?, such as have been enumerated 
above, are liable to occur suddenly and unexpectedly in mild as well as 
severe cases, it is unwise to make an unconditional favorable prognosis 
till the patient is well advanced in convalescence. Safety is not insured 
till two or three weeks after the eruption. 

Some patients, who have passed through scarlet fever, die of asthenia, 
in consequence of the anaemic state which the fever has produced. They 
have not sufficient vigor to recover, although no serious complication or 
sequel has occurred. Death in the desquamative stage or subsequently 
is more frequently due to the renal affection than to any other cause. The 
nephritis gives rise to dropsies, which are fatal, or to uraemic convulsions 
and coma. Sudden and unexpected deaths are not uncommon in scarlet 
fever, and although they may, sometimes, occur from uraemia, their usual 
immediate cause, as others and myself have had the opportunity to ob- 
serve in the cadaver, is the formation of ante-mortem heart-clots. 



206 SCAKLET FEVER. 

Treatment. — It should be borne in mind that scarlet fever cannot be 
shortened or aborted, and that the indications are to sustain the strength, 
reduce excessive fever, and prevent complications. There is no known 
remedy which destroys the poison, when once it has obtained lodgment in 
the system, and begun to produce its characteristic symptoms. Those 
agents, as carbolic acid, salicylic acid, etc., which are most highly es- 
teemed as disinfectants, cannot be safely used in efficient doses to antago- 
nize the poison in the system, since such doses would seriously impair the 
nutrition and molecular action in the tissues. The expectations raised in 
the minds of many, by the employment of salicylic acid, in the treatment 
both of scarlet fever and diphtheria, have been disappointed, and the use 
of the sulpho-carbolates has not, I think, been attended by any better 
success. 

The following is the plan of treatment which can be confidently recom- 
mended as appropriate in ordinary cases : The patient should remain in 
the same room till desquamation is accomplished, and he should stay in 
bed till the fever and the eruption have ceased. The temperature of the 
room during the eruptive and febrile stage should be about 60° ; during 
the desquamative stage, when the patient may be allowed to leave the 
bed for some hours, the temperature of the room should be uniformly at 
70° to 75°, and the air should be constantly pure from sufficient ventila- 
tion, without exposing the patient to currents. The linen should be 
changed every day or second day. 

The external treatment of scarlet fever by measures designed to ab- 
stract heat is important. A temperature not exceeding 103° is usually 
safe, so as not to require special treatment, but a temperature at or above 
104° rapidly exhausts the strength and involves great danger. The high 
temperature can be reduced without shock or injury to the child by the 
judicious use of cold water externally, and by inunctions. The cold-water 
treatment is not required unless the temperature exceeds 103°, and it is 
urgently required if it exceed 105°. It has been applied in different ways. 
At one time in the N. Y. Foundling Asylum the patients were stripped, 
and placed for a short time in a bath at 80°, but it caused such fright and 
excitement with a portion at least of the cases, that this treatment was 
discontinued. A preferable way of applying this treatment is by Ziemssen's 
bath, in which water is employed at a temperature of 90°, and gradually 
cooled to 11°. In most cases, however, I prefer to reduce the tempera- 
ture by the constant application to the head of cloths wrung out of 
ice water, or if the temperature be above 104° of a bladder containing 
ice, with or without a single thickness of muslin underneath. At the 
same time, as a potent means of reducing heat when there is great eleva- 
tion of temperature, a similar application should be made from ear to ear 
over the neck. Cold applied over the great vessels of the neck promptly 
abstracts heat from the blood, while it diminishes the pharyngitis adenitis 



TREATMENT. 207 

and cellulitis, which is an important gain. At the same time it is proper 
to sponge frequently the hands and arms with the cool lotion, and apply 
around them as well as along the sides of the face, one or two thick- 
nesses of muslin wet with the same. By such measures, which are agree- 
able to the patient and without any shock or perturbating effect on the 
system, we can reduce the temperature two or three degrees. By adding 
alcohol, or one of the alcoholic compounds to the water, the popular ob- 
jection to the use of cold water is overcome. I seldom use the wet pack, 
but have seen benefit from it when other measures failed to produce 
sufficient reduction in temperature. The patient is placed upon a 
mattress protected by oil-cloth, and is covered by a sheet wrung out of 
water at a temperature of TO , which is that of ourCroton in midsummer. 
This is covered by one or two blankets. In thirty to forty minutes the 
patient is returned to bed, and will be found to have a temperature per- 
haps two or three degrees less than before the bath. If the patient be 
very feeble, and with sluggish circulation, reaction from the packing is 
sometimes tardy and incomplete. The extremities remain cold, and in- 
creased stimulation is required. There is danger under such circum- 
stances that some internal inflammation may arise. Therefore, for most 
cases I prefer the other method mentioned, rather than the general bath 
or pack. The intelligent and observing sister who 'for years has had 
charge of the quarantine wards of the New York Foundling Asylum, tells 
me that the gradual but constant abstraction of heat by the rubber bags 
and sponging has usually operated better than the quick and great 
abstraction by the general bath. 

Trousseau employed cold effusions in sthenic cases, which were attended 
by high temperature, and other grave symptoms. He employed them in 
the first stage of the malady, and considered them especially useful when 
nervous symptoms predominated. He placed the patient naked in a bath- 
ing-tub, and directed three or four pailf uls of water to be thrown over him 
in a space of time varying from a quarter of a minute to one minute, after 
which he was returned to bed, and covered with the bedclothes without 
being wiped. Reaction immediately occurred, often with more or less 
perspiration. This treatment was repeated once or twice daily according 
to the gravity of the symptoms. Trousseau, alluding to the affusion, 
says, " 1 have never administered it without deriving some benefit. " I 
am sure, however, that the cautious physician, who wishes to avoid meas- 
ures which excite and frighten the patient, will prefer other methods. 

Inunction of the surface of the body and extremities has long been in use. 
An unpleasant symptom in severe cases, and one which increases the rest- 
lessness of the patient, is the pungent heat of surface. Frequent inunc- 
tion reduces this, relieving the dryness of the skin, and so increasing the 
comfort that the patient asks for it. Leaf lard answers for this purpose, 
and being inexpensive, is within the means of the most destitute family. 



208 SCARLET FEVER. 

1 prefer using butter of cocoa in cake, or vaseline, to each ounce of 
which five or six drops of carbolic acid may be added. Not only does 
inunction have the local effect which has been described, but it is stated 
to diminish sensibly the rapidity of the pulse, and the general temperature 
of the body. 

Scarlet fever when mild, and without complication, requires little treat- 
ment, but every case, however mild, should be kept quietly in bed. If 
there be restlessness, an occasional dose of bromide of potassium with a 
warm mustard foot-bath will give relief, and this with the inunction would 
suffice for most of those lightly affected. There is, however, in all cases 
more or less pharyngitis, and as mild cases as well as severe may become 
complicated with diphtheria in localities where diphtheria is endemic or 
epidemic, I employ the following mixture even in the mildest cases ; 

^ . Tine, ferri chloridi, 5ij 5 
Potas. chlorat., 5i-ii >" 
Syr. simplic, | iv. 

Give one teaspoonful every hour or every second hour, to a child of 
four or five years. The mildest cases are not less liable to nephritis than 
those of a severe type, so that during the disease, and in convalescence, 
they require cautious management as regards exposure to currents of air, 
or sudden changes of temperature, for all those agencies which check 
cutaneous transpiration may lead to development of nephritis. 

In the average cases, that is, in those in which the temperature is about 
102° or 103°, and there are no dangerous symptoms, I prescribe the above 
potash and iron mixture, to be given as above, except that on each fourth 
or sixth hour I administer quinine, dissolved in the elixir adjuvans, or 
other convenient vehicle, two grains to a child of four or five years. If 
the pharyngitis begin to abate, or be mild, I often prescribe the following 
mixture in place of the iron and potash. In all cases it will be found 
useful during the declining period. 

]£. Amnion, carbonat., 

Ferri et amnion, citrat., aa 3 ss ; 
Syr. simplic, | iv. Misce. 
Dose, one to two teaspoonfuls every second or third hour. 

In severe cases, in which the pulse is quick and weak, the temperature 
above 104°, the capillary circulation languid, the stomach irritable, and 
perhaps the bowels loose, while the nervous system is profoundly affected, 
as shown by drowsiness, delirium, or great restlessness, the condition is 
one of great danger, and measures designed to give relief are urgently 
required. As a temperature above 104° and especially above 105° rapidly 
exhausts the system, the antipyretic treatment by water, recommended 
above, should be employed, and perhaps a large dose of sulphate of 
cuiinise. Aconite and veratrum viride should never be prescribed in these 



TREATMENT. 209 

cases, as they are depressing. Digitalis is preferable to them, but it is 
less antipyretic than quinine. Five grains of quinine may be given three 
times daily to a child of five years. If the stomach be irritable, and it often 
is in these cases, ten of the bisulphate may be given in a suppository, 
.and repeated if needed. While all but the mildest cases require the 
use at regular intervals of alcohol, either in the form of wine whey or 
milk punch, these severe cases, which are designated malignant, require 
alcoholic stimulants in larger and more frequent doses. If the nervous 
system be profoundly affected, so as to produce great restlessness, or other 
symptoms precursory of convulsions, the use of the bromide of potassium 
is indicated. While cool water may be employed externally for its anti- 
pyretic effect, it is proper to aid in allaying the nervous symptoms by a 
hot mustard foot-bath. If convulsions occur, which are usually attended 
by the disappearance of the eruption, this bath should be employed at 
once, or a general warm bath. 

The large antipyretic doses of quinine should in general only be em- 
ployed for two or three days, as its longer use might involve danger from 
its toxic properties. Afterward the smaller dose should be given. Digi- 
talis will often be found useful, as a heart tonic, when the pulse is rapid 
and weak. One teaspoonful of the infusion, or four or five drops of the 
tincture, may be given every four hours to a child of five years. In 
these grave cases, which are characterized by great elevation of tempera- 
ture, rapid pulse, and prostration, carbonate of ammonium will also be 
found useful, administered in decided doses between the quinine or digi- 
talis. I prescribe it dissolved in water, so that each teaspoonful contains 
from three to five grains, and direct it to be given in milk, which is the 
best vehicle for it. 

If the patient with malignant scarlet fever live till the fifth or sixth 
day, the urgent nervous symptoms begin to abate, and the angina then 
commonly demands more attention. The treatment of the throat has of 
late years become very important, since so many cases are nowadays 
complicated with diphtheria. For external treatment I prefer the cold 
compress, or India-rubber bag, which I have advised above, during the first 
three or four days, if the case be severe, and there be much elevation of 
temperature. If the fever be mild, camphorated oil or a light flaxseed 
poultice may be preferable. The poultice appears sometimes to give 
more relief to the tenderness than any other application. I do not, 
however, consider treatment of the neck important in mild cases, and I 
limit its use to those who have much inflammation and febrile movement. 
The treatment of the faucial surface is of more importance, and for this I 
prefer the use of the hand atomizer. This should be used every two to 
four hours, and if the instrument be well constructed, as Richardson's hard- 
Tubber, or Delano's metallic, and in good condition, six to twelve com- 
pressions of the bulb are sufficient, if the following mixture be used : 



210 SCARLET FEVER. 

3. Acid, carbolic, gtt. xxxij ; 
Potas. clilorat., 3 iij ; 
Glycerinse, | ii ; 
Aquas calcis, § vi. Misce. 

This spray should be employed at least every two hours, if any exuda- 
tion adhere to the inflamed surface. For infants I dilute the mixture with 
an equal quantity of water. Or the following may be employed, which is 
a more active solvent of pseudo-membranes than the other: 

I£ . Liquor potassse, 3 i ; 
Aquas, § v. Misce. 

The muco-purulent discharge from the nostrils in connection with the 
pharnygeal swelling often so impedes respiration that it proves annoying 
to the patient and increases his suffering. For this, warm lime-water, 
with about one two hundredth part of carbolic acid, should be injected 
into the nostrils ; or, which I prefer, thrown into them in the form of 
spray by the atomizer. Richardson's and some others have a cap or 
point designed for the nostrils. The atomizer employed for the fauces is 
very effectual in removing the muco-pus, which often renders the res- 
piration noisy and embarrassed in severe cases, for it dilutes the secre- 
tion and provokes a strong cough. 

The abscess along the neck, which often results from severe adenitis 
and cellulitis, should be opened early, since it is painful, causes pro- 
traction of the fever, loss of strength, and restlessness, and as it is apt to 
be diffused, endangers absorption of the elements of pus. 

The renal affection is often more dangerous than the scarlet fever. A 
clear appreciation of its therapeutic indications is important, since by 
judicious treatment many recover whose lives would inevitably be sacri- 
ficed by improper measures. As there is in these cases active hyperemia 
of the kidneys, having an inflammatory character, diuretics w r hich stimu- 
late these organs should not be given, at least till this pathological state 
has, in a measure, abated. As the eliminative functions of the skin and 
of the intestinal mucous surface are to a considerable extent vicarious with 
that of the kidneys, diaphoretic and purgative remedies are required. By 
free diaphoresis the ill effect of arrested or diminished renal secretion is, 
for a time, averted. Treatment to produce diaphoresis should vary some- 
what in different cases. It should in most patients be commenced by the 
use of a warm general or foot-bath, and the patient then be covered in 
bed. If free perspiration be not produced, it may be promoted by sur- 
rounding the body, either with hot dry or moist air. Hot dry air may be 
produced by burning alcohol in a thin layer upon a plate under a chair 
upon which the patient sits, while he is surrounded by a blanket, or he 
may be covered in bed, and the hot air introduced under the bedclothes 
by a common small sheet-iron pipe, the further extremity of which resting 



TREATMENT. 211 

on the floor contains an alcohol- lamp. Hot moist air may be produced 
by placing against the patient one or more bottles of hot water, sur- 
rounded by a wet cloth. The steam arising from this, and enveloping the 
body and limbs, produces a prompt sudorific effect. There is in use in 
this city, in the treatment of these and similar cases requiring diaphore- 
sis, a convenient apparatus for generating steam. It consists of a cylinder 
pierced with holes for the admission of air, and containing a spirit-lamp 
over which is a pan or pail holding a little water. The patient, nearly 
denuded, is placed in a chair, with the apparatus by his side, and is cov- 
ered with a blanket so that the steam surrounds the body. This gives 
rise to free perspiration, which continues after the patient is placed in 
bed. This treatment may be repeated each day, if the patient require it, 
while diaphoretics and laxatives are given. The diaphoretics which have 
heretofore been most employed in this affection are the acetates of ammo- 
nium and potassium, the bitartrate and citrate of potassium, and spiritus 
aetheris nitrosi. These agents employed singly or variously combined in- 
crease the diaphoretic effect, if used in connection with the external measures 
described above, which are calculated to produce diaphoresis. If employed 
with the surface cool, they act rather as diuretics than diaphoretics. 

Pilocarpin, the muriate of which is most conveniently used, as it is 
soluble in water, is an efficient sudorific and useful remedy for scarlati- 
nous dropsy, if the action of the heart be strong. Ether may be employed 
with it, or the amount of alcoholic stimulant increased at the time of its 
exhibition to guard against any depressing effect. To a child of two 
years one-twentieth of a grain may be given every six hours, by the mouth. 
It may also be employed hypodermically, as one-twentieth of a grain for a 
child of five years. It should be given gratiously, or not at all if the 
heart's action be weak. 

Diuretics, which do not stimulate the kidneys, are proper at an early 
period of the renal malady, and in my opinion digitalis is more useful 
than any other internal remedy. I do not hesitate to administer it from 
the first day, often in combination with acetate of potassium, which in addi- 
tion to a diaphoretic and diuretic has a laxative action. Digitalis has the 
confidence of the profession of New York more than any other medicine, 
both for the nephritis of children and of adults. One teaspoonful of the 
infusion should be given every fourth hour to a child of three to five 
years. The following is a good formula for a child of five years in good 
general condition : 

5- Potas. acetat., § ss ; 

Inf us. digital., § vj. Misce. 

For the older robust children with scarlatinous uraemia and serous effu- 
sions few remedies afford so much relief in the commencement as cathartics 
of a hydragogue nature. A mixture of jalap and cream of tartar, pulvis 
jalapae compositus of the Pharmacopoeia, meets the indication. Even in 



212 SCARLET FEVER. 

children somewhat reduced medicines of this nature are often required. 
Cathartics are more certain in their effects than either diaphoretics or 
diuretics, and, therefore, they should be given in urgent cases in which it 
is necessary to remove the urea or serum as speedily as possible. An 
excellent prescription in many of these cases, and one from which I have 
obtained a good result, is the following : 

5 . Podophyllin, gr. j ; 

Saccli. alb., 3j. Misce. 
Divid. in chart. No. viii.-xii. 
Dose, one powder, according to circumstances. 

After the use of laxative agents, the kidneys, being less congested on 
account of the diversion that has occurred, often begin to excrete more 
freely. But if the patient be anaemic, or enfeebled, and the symptoms 
are not urgent, cathartic or other depressing remedy is inadmissible. 
Cases like the following, from my note-book, are not infrequent. A little 
boy, pale and scrofulous, began to have anasarca, after scarlet fever, chiefly 
of the scrotum, and accompanied by a moderate degree of ascites. The 
urine, which was passed in nearly the normal quantity, contained albumen. 
This patient gradually and fully recovered, with no treatment except the 
use of an oil-silk jacket over the kidneys and abdomen, to promote dia- 
phoresis, and the use of iron. Such a case actively treated by eliminatives 
would, probably, have proved fatal. Variation in measures is therefore 
demanded, according to the state of the patients, but digitalis, being a 
heart tonic, is very useful in the asthenic as well as sthenic cases. 

It is evident from what has been stated above that the condition of the 
ear should be closely observed in and after scarlet fever. If the patient 
have earache, considerable relief may be obtained in the commencement 
by dropping a few drops of laudanum and sweet oil into the ear, and 
covering the ear by some hot application, either dry or moist, which 
will retain the heat. A favorite popular remedy in the tenement houses 
of New York, is a bag of dry and hot chamomile flowers, bound over the 
ear. Hot water syringed into the ear is also beneficial, and sometimes 
a leech applied at the base of the tragus aids materially in checking the 
inflammation in the first day or two. In most cases, however, the otitis 
continues, and the drum of the ear should be inspected daily. 

Dr. Albert II. Buck, of New York, in a highly instructive paper on 
this subject, read before the International Medical Congress in 1876, 
writes : ' ' This is the time when paracentesis of the membrana tympani 
produces such beneficial effects. In this one slight operation, which in 
itself is neither dangerous nor very painful, lies the power to prevent the 
whole train of disagreeable and dangerous symptoms." Dr. Buck relates 
an instructive example. The age of the patient was three years, and the 
earache had been complained of only about twenty-four hours. * ' Towards 
morning," said he, " I was sent for, as the pain had become constant. 



TREATMENT. 213 

An examination with the speculum and reflected light showed 
an (edematous and bulging membrana tympani (posterior half), the neigh- 
boring parts being very red, though as yet but little swollen. In the most 
prominent portion of the membrane I made an incision, scarcely three 
millimetres (one tenth inch) in length, and involving simply the different 
layers of the membrana tympani. This was almost immediately followed 
by a watery discharge (without the aid of inflation), which ran down over 
the child's cheek. At the end of three or four minutes the child had 
ceased crying, and in less than a quarter of an hour she was fast asleep. 
At first the discharge was very abundant and mainly watery in character, 
but it steadily diminished in quantity, and became thicker, till finally on 
the fourth day it ceased altogether. On the tenth day the most careful 
examination of the ear could not detect any trace of either the inflamma- 
tion or the artificial opening. ' ' This simple operation had probably saved 
the ear from ulceration of the drum, long-continued suppurative otitis, and 
perhaps from permanent impairment of hearing. It is evident that the 
operation should be performed early, before the ear is irreparably injured.* 
But if the otitis have continued unchecked by treatment till the pent- 
up secretions, after days and nights of suffering, have escaped by ulceration 
through the drum, the opportunity for prompt and certain cure is passed. 
Still the patient under these circumstances may quickly recover, or there 
may be the other alternative described above, in which the ear is badly 
damaged, and a chronic inflammation established in the walls of the tym- 
panum, giving rise to an offensive otorrhoea. Under such conditions the 

* Dr. 0. D. Pomeroy, an experienced and skilful aurist of New York, lias 
kindly furnished the following particulars in reference to this operation : " The 
forehead mirror should be worn in order to leave the hands free to operate, using 
either artificial or daylight. A good-sized speculum is introduced into the 
meatus. Then an ordinary broad needle, about one line in diameter, with a 
shank of about two inches, such as oculists use for puncturing the cornea, 
should be held between the thumb and fingers, lightly pressed, so as not to dull 
delicate tactile sensibility. The part being well under sight, the most bulging 
portion of the membrane should be lightly and quickly punctured, with a very 
slight amount of force. The posterior and superior portion of the membrane 
is most likely to bulge. The chorda tympani nerve ordinarily lies too high up 
to be wounded. The ossicles are avoided by selecting a posterior portion of the 
membrane. After puncture the ear should be inflated by an ear-bag, whose 
nozzle is inserted into a nostril, both nostrils being closed, so as to force the fluid 
from the tympanum. The puncture may need to be repeated, at intervals of a 
day or two, provided that the pain and bulging return. In my opinion paracen- 
tesis may frequently be rendered unnecessary by the timely use of one or two 
leeches applied to the meatus. Leeching employed at the right time rarely fails 
to subdue the pain and inflammation. The posterior face of the tragus is ordi- 
narily the best place for applying the leech, but it may be applied in front of the 
ear or behind wherever the tenderness on pressure is greatest. 

"New York, Dec. 13, 1878." 



214 SCARLET FEVER. 

same internal treatment is indicated which we make use of in suppurative 
inflammations of bone in other parts of the system. The internal use 
of cod-liver oil and iodide of iron is indicated, especially for those 
patients who seem to have the strumous diathesis, the object being 
to prevent extension of inflammation, and to produce a more healthy state 
of system, which will facilitate the healing process. The following, or 
some equivalent carbolized solution, should be syringed from one to three 
times daily into the ear. It should be used warm with an ear syringe : 

R. Acid, carbolic, 3 ss ; 
Glycerinae, § ij ; 
Aquse, 3 iv. Misce. 

We have stated above that during convalescence precautions should be 
taken to prevent the patient's catching cold, so as to diminish the liabilitv 
to the sequelae, which have now been described. He should not be 
allowed to go in the open air in unpropitious weather till a month after 
the fever. An oil-silk protection, worn over the under-clothes for a 
month or two, from the time that the febrile symptoms begin to decline, 
and covering the lumbar region, affords considerable protection to the 
kidneys. 

Prophylaxis. — Since the period of Jenner's discovery of the r>rophy- 
lactic power of vaccination, as regards smallpox, the attention of the pro- 
fession has been frequently directed to the prevention of scarlet fever. 
Belladonna has been employed as a prophylactic, *and recommended, but 
its use for this purpose has been fruitless, and is now nearly or quite dis- 
carded. The most reliable, and, indeed, the only efficient prophylactic, 
is isolation, and the proper employment of disinfection in the sick-room 
and upon the patient. There can be no doubt that most of the excretions 
of a child sick with this malady contain the scarlatinous virus, as do alsO 
the cells of the epidermis, which are thrown off during convalescence and 
minute particles of which are wafted away as motes in the air. By the 
proper application of washes, which contain carbolic acid, to the fauces 
and nostrils, the secretions from these surfaces are to a great extent disin- 
fected. If otorrhcea occur, the ear should be syringed with warm water 
containing carbolic acid in the proportion of one drachm to the pint, and 
this should be continued after convalescence, for cases occur which show 
that the discharge from the ear is probably the medium by which 
the virus is communicated, even as late as the fourth week after the 
disappearance of the rash. Children in the midst of the fever usually 
experience a degree of relief from inunction of the surfaces, and if car- 
bolic acid be added to the substance which is employed for this purpose, 
and the inunction be made twice daily over the entire surface, contamina- 
tion of the air through the exhalations and exfoliations from the skin is in 
great part prevented. A convalescent child should not be allowed to 



PROPHYLAXIS. 215 

mingle with other children till three or four weeks have elasped, and all 
who are liable to take the malady should be excluded from the room in 
which a case has occurred for a longer period. 

The New York Health Board enforce the following excellent regula- 
tions against scarlet fever as well as measles : 

" Care of Patients. — The patient should be placed in a separate room, 
and no person except the physician, nurse, or mother, allowed to enter 
the room, or to touch the bedding or clothing used in the sick-room, 
until they have been thoroughly disinfected. 

" Infected Articles. — All clothing, bedding, or other articles not abso- 
lutely necessary for the use of the patient, should be removed from the 
sick-room. Articles used about the patient, such as sheets, pillow-cases, 
blankets, or clothes, must not be removed from the sick-room until they 
have been disinfected, by placing them in a tub with the following disin- 
fecting fluid : eight ounces of sulphate of zinc, one ounce of carbolic acid, 
three gallons of water. 

1 ' They should be soaked in this fluid for at least one hour, and then 
placed in boiling water for washing. 

" A piece of muslin, one foot square, should be dipped in the same 
solution and suspended in the sick-room constantly, and the same should 
be done in the hallway adjoining the sick-room. 

' ' All vessels used for receiving the discharges of patients should have 
some of the same disinfecting fluid constantly therein, and immediately 
after use by the patient be emptied and cleansed with boiling water. 
Water-closets and privies should also be disinfected daily with the same 
fluid, or a solution of chloride of iron, one pound to a gallon of water, 
adding one or two ounces of carbolic acid. 
" All straw beds should be burned. 

" It is advised not to use handkerchiefs about the patient, but rather 
soft rags for cleansing the nostrils and mouth, which should be immedi- 
ately thereafter burned. 

,k The ceilings and side walls of the sick-room after removal of the 
patient should be thoroughly cleaned and lime-washed, and the woodwork 
and floor thoroughly scrubbed with soap and water." 

By such measures of prevention there can be no doubt that the number 
of cases of scarlet fever would be greatly reduced. Dr. William Budd, 
of Bristol, England, has for years recommended similar precautions in 
the families which he attends, and the following is his testimony in regard 
to the result : " The success of this method, in my own hands, has been 
very remarkable. For a period of nearly twenty years during which I 
have employed it in a very wide field, I have never known the disease to 
spread in a single instance beyond the sick-room, and in very few 
instances within it. Time after time I have treated this fever in houses 
crowded from attic to basement with children and others, who have 



216 ROTHELN. 

nevertheless escaped infection. The two elements in the method are, 
separation on the one hand, and disinfection on the other." (British 
Medical Journal, January 9, 1809.) 



CHAPTER III. 

ROTHELN. 

The disease known as rotheln has heretofore been rare in America. 
In the Eastern continent, on the other hand, it appears to have been 
known for many years, and American physicians frequently designate it 
German or French measles. Meagre and imperfect descriptions of this* 
malady have appeared in some of the British journals, and cases quite 
fully detailed have been published by British physicians. 

Rotheln is not entirely a new disease in this country, though most 
American physicians never saw a case of it until within the last decade. 
Cases occurring in and about Boston were described by Dr. Honans, Sr., 
in 1845, and at a later date, namely in 1853 and 18*71, B. E. Cottingand 
Mr. D. Howard saw cases, and described them in papers read before 
local societies. (See Boston Med. and Surg. Journal, March 15th, 
1873.) In 1874, Dr. Caleb Green, of Homer, Cortland County, New 
York, an accurate and intelligent observer, also witnessed an epidemic. 

This hitherto rare and interesting malady occurred in New York City 
as an epidemic in 1873 and 1874, attaining its maximum prevalence in 
March and April of the latter year, after which it declined, occasional 
cases occurring throughout May. This, so far as I can learn, was the first, 
occurrence of rotheln in this locality. In a general practice of more than 
twenty years, extending over a considerable portion of this city, I had 
previously seen nothing like it, and other older physicians, having a large 
general practice, have informed me that they consider it an entirely new 
disease with us. Those who believe that they have occasionally observed 
isolated cases of it, previously to the epidemic, probably refer to 
roseola. 

The first case which I met with occurred in the middle of December, 
1873, in West Seventy-first Street, in the northern suburbs of this city. 
A few weeks later cases were so numerous in the more thickly populated 
sections of New York as to attract the attention of many physicians. It 
was evident that a disease had appeared with which we were not familiar, 
and as the eruption occurred in points and small circumscribed patches, it 
was usually designated by the physicians, in want of a more accurate 
name, epidemic roseola, or was spoken of as a spurious measles. Physi- 



RoTHELN. 217 

cians who were familiar with foreign medical literature saw the resem- 
blance between these cases and those of rotheln, as described by British 
and continental writers, but in certain at least of the foreign cases the 
duration of the rash was said to be seven days (Liveing, London Lancet, 
March 14th, 1874, and Med. News and Library, May, 1874), whereas in 
the cases in New York it commonly disappeared by the fourth day. This 
discrepancy, however, was not sufficient to invalidate the belief in the 
identity of the New York disease with the foreign rotheln. It was readily 
explained by the difference in the seasons in which the cases occurred, 
for Liveing observed his cases in June and July, and, as we will see, the 
greater the external heat, the longer the duration of the eruption. 

Between the middle of December, 1873, and May 1st, 1874, I had ob- 
served and treated this malady in eighteen families. Cases occurred in 
three other families living in the same houses with some of those which 
I attended, and, as they were fully and clearly described to me, so that 
there could be no doubt as to their nature, I have included them in my 
statistics. The total number of cases in these twenty-one families was 
forty-eight. During May, when the epidemic was declining, I saw six 
additional cases, occurring singly, making a total of fifty-four. Their 
ages are given in the following table ; 

Age. Cases. 

From eight months to one year, 2 

" one year to two years, ....... 4 

" two years to five years, ... ... 16 

" five " " ten " 23 

" ten " " fifteen " 3 

" fifteen years to thirty years, 6 

Total number of cases, ...... 54 

The age of the youngest patient was eight months, and that of the oldest 
thirty years. Seventy-two per cent of the total number were between the 
ages of two and ten years ; so that rotheln is pre-eminently a disease of 
childhood. Individuals in and beyond the middle period of life seem to 
have nearly an immunity from it. The age of the oldest patient of whom 
I was informed in the epidemic of 1873 and 1874 was about forty years. 
On March 25th, 1873, during my attendance in the N. Y. Foundling 
Asylum, rotheln appeared in a boy of four years : in the following month 
about thirty more cases occurred in this institution, all children, while 
among the large number of female nurses and employees who were chiefly 
between the ages of twenty and thirty years, all but three escaped. 

From 1874 to 1880 rotheln did not prevail in New York, unless now 
and then an isolated or sporadic case, the nature of which was not recog- 
nized and which was supposed to be roseola. On August 9th, 1880, two 
cases appeared in different wards of the N. Y. Foundling Asylum, when 
it was remembered that two weeks previously these children had been ex- 



218 ROTHELN. 

posed to a patient in the hospital, attached to the institution, who had 
what the physician in attendance supposed at the time to be roseola. 

Commencing with these two cases an epidemic occurred in the asylum, 
mild in type, affecting only a few at a time, but extending over several 
months, until about sixty inmates, chiefly children, were attacked. 
Toward the close of 1880, rotheln began to appear in the northern part of 
the city, in which the asylum is located, and over which my practice 
extends. Its maximum prevalence was attained in the latter part of March 
and April, 1881, when it particularly attracted the attention of physicians. 
A large proportion of the children attending certain public and private 
schools were attacked. It occurred in seventeen families in my practice. 
The ages of the patients in these families are given in the following 
table : 

Age. Cases. 

From one to two years, 3 

" two" five " 8 

" five" ten " 18 

" ten " fifteen" . . . 11 

There were two cases over fifteen years, aged respectively 
twenty-two to forty-two years, 2 

Total number of cases, 42 

Premonitory Stage. — Premonitory symptoms are, in most instances, 
absent, or so mild as to attract but little attention. It not infrequently 
happened in the New York epidemics that the parents or the teachers in 
the schools were first made aware of the illness of the children by observ- 
ing the eruption. In some instances, children were sent from school, not 
because they felt too ill to remain, but on account of the unusual ap- 
pearance of the skin. Sometimes, however, in those old enough to ex- 
press their sensations a premonitory stage of some hours or a day, or even 
of longer duration was present ; consisting of such symptoms as usually 
occur when one has taken a severe cold, as languor, pain in the head, trunk, 
or limbs. The resident physician of the New York Foundling Asylum 
was so ill with rotheln that he was confined to his bed during the first day 
of the disease. Now and then patients experience nausea, previously to the 
eruption, and in the first and second days of the eruptive stage. In only 
one instance did I observe grave prodromic symptoms. A boy aged 
eight years was suddenly seized with clonic convulsions, and while in a 
warm bath for the relief of these, the rash appeared upon those parts of 
the body which were immersed in water. 

Symptoms. — Tegumentary System, (a) The Skin. — The eruption com- 
monty commences upon the forehead, around the ears and along the neck, 
as in measles. Occasionally it may appear upon the back or chest, as in the 
above-mentioned case, in which the hot water accelerated its appearance. 
Commencing above the efflorescence travels downward, appearing after 



SYMPTOMS. 219 

some hours upon the lower part of the trunk and on the legs, resembling 
in this respect the eruption of measles and scarlatina. It occurs upon 
all parts of the integument, except the scalp and palmar and plantar sur- 
faces. In the majority of the cases which I have seen it gradually faded 
away, disappearing by the fourth day, but on children who were kept 
warm in bed, or in warm apartments, it remained longer than on others. 
In many instances traces of the rash were still visible several days after re- 
covery when the patients were heated by exercise or excitement. It 
reappeared at times, though indistinctly, on a girl of thirteen years for 
three weeks. In most of the cases in the New York epidemics the eruption 
commonly occurred in points and circular spots, somewhat smaller than 
those of measles. These points and spots were numerous and thickly set, 
so that, in the aggregate, they covered at least half of the surface, while 
between them the skin presented nearly or quite its normal appearance. 
The general aspect in most cases was more like that of measles than that 
of scarlatina, but in exceptional instances the skin between the points and 
spots had a redness similar to that of erythema, and the resemblance was 
very like the scarlatinous efflorescence. Thus, in a boy of three years the 
eruption so closely resembled the scarlatinous over the trunk, that were it 
not that the temperature was constantly below 100° and all febrile move- 
ment ceased within three or four days, I would probably have con- 
sidered the malady a mild scarlatina. In certain patients the eruption, 
beginning in circumscribed spots, like that of measles, becomes in two or 
three days confluent so as to resemble that of scarlatina, while over other 
parts the spots remain discrete. This was the character of the eruption 
upon the third and fourth days on the extremities of a little boy in the 
Foundling Asylum. The rash is attended by considerable itching, from 
which, indeed, many patients suffer more than from all other symptoms. 

The eruption disappears on pressure, produces a slight roughness of 
the surface, as ascertained by passing the fingers gently over it, and 
usually fades away without desquamation. Exceptionally there is a 
slight branny exfoliation, and in one of my patients this was as consider- 
able over the abdomen as in cases of scarlatina. 

(6) The Mucous Membrane. — In connection with the cutaneous erup- 
tion a mild inflammation also occurs upon the mucous membrane cover- 
ing the fauces, buccal cavity, and nostrils, and upon reflections of this 
membrane over the eyes and eyelids, i.e., upon the conjunctiva. In 
certain patients this inflammation is scarcely appreciable, but in the ma- 
jority it arrests attention at once. It produces a suffused, reddish or 
weak appearance of the eyes, with a moderately increased lachrymation. 
On everting the eyelids the palpebral conjunctiva is seen to be injected. 
In certain patients a moderate puriform secretion collects at the inner 
angle of the eyelids. In occasional cases the conjunctivitis causes oedema 
of the lids, usually slight and likely to be overlooked by the physician, 



220 KOTHELN. 

but in three instances which I now recall to mind the mothers of the 
children directed my attention to the swollen state of the lids. In one of 
these, an infant of twenty-three months, the tumefaction was so great, 
commencing about the time the eruption began to fade, that light was 
totally excluded from the eyes, and it was impossible to ascertain their 
condition. The skin over the eyelids retained nearly its normal appear- 
ance, and a puriform secretion appeared between the lids. In three or 
four days the oedema of the lids and the hyperaemia of the conjunctiva 
rapidly declined. The coryza is in most cases sufficient to cause an un- 
pleasant sensation in the nostrils and provoke sneezing, but the flow 
from the nostrils, though present, was in no instance under my observa- 
tion as abundant as in ordinary cases of scarlatina or even of measles. 
The fauces present an injected appearance, and in severe cases there is 
moderate swelling of the tonsils. The same catarrhal hyperaemia is also 
seen in spots or patches, more or less diffused, upon the buccal surfaces. 
Both the faucial and buccal catarrh are less in degree, however, than in 
cases of rubeola and scarlatina, which have an equal intensity of cu- 
taneous eruption, and this fact has aided me in differential diagnosis. 

The Respiratory System. — In both the epidemics which I have wit- 
nessed the mucous membrane of the larynx, trachea, and bronchial tubes 
participated only slightly in the inflammation which involved the nasal, 
buccal, and faucial surfaces. Many of my patients had no cough, but 
others had a mild cough lasting for a few days, but with normal respira- 
tion. It was due apparently to a very mild catarrh of the respiratory 
tract at the time when the nasal and conjunctival surfaces were the most 
affected. It subsided in a few days without treatment. In no case do I 
recollect that there was any hoarseness. 

The Digestive System. — The tongue in rotheln is moist and of normal 
appearance or covered by a slight fur. The appetite may be impaired, 
but is not wanting in uncomplicated cases. The patients sometimes say 
that it is nearly the same as in health, the thirst is slight, and the bowels 
are regular. 

Nausea is not infrequent, and vomiting was, in several cases in my 
practice, one of the initial symptoms. In certain patients it also occurred 
on the first or second day of the eruption. In others there was no 
nausea, so far as I could learn, either immediately before or during the 
prevalence of the disease. This symptom is less frequent in rotheln than 
in scarlet fever, but is as common apparently as in measles. I have 
never found albumen in the urine, though I have examined that passed by 
several patients. This secretion did not appear to be abnormal except as 
it contained urates, so common in febrile states. 

The Pulse and Temperature. — The largest number of accurate daily 
observations relating to the temperature was, I think, that of Doctor 
Reid in the New York Foundling Asvlum during the month of March, 



COMPLICATIONS — NATURE. 221 

1874. He has kindly furnished me with his statistics relating to this 
symptom as follows : " The number of closely observed cases in which 
the temperature was taken was twenty-four. In seventeen of the cases 
the temperature ranged from 97° to 99°, in six it reached 100°, 100£°, 
and lOOf ° ; in one it reached 103^° on the second day of the eruption, 
but remained so elevated only one day." In certain patients Doctor 
Reid observed what he designates, " a tendency to the development of an 
ephemeral fever." These observations correspond closely with those 
made by myself during the same epidemic. Thus, in 16 cases I found 
the axillary temperature taken each day to be constantly between 98° and 
100°, with a pulse under 110 , except in one case, in which it numbered 
124 . In certain other patients a more decided febrile movement, last- 
ing from one to two or three days, occurred, usually in the commence- 
ment of the malady. Thus, a girl aged three and a half years had a 
temperature of lOlf ° and a pulse of 128 . In another instance the pulse 
was 124 and the temperature 102°. In another, a girl of three and a half 
years, there was active febrile movement occurring without apparent cause 
on Saturday night, but abating on the following day. She seemed well 
until the following Tuesday, when the febrile movement returned and the 
eruption appeared. On Thursday the temperature from 102° to 103° 
fell to 99£°, and within a day or two she was convalescent. In two other 
patients from two to four days after the disappearance of the eruption an 
accession of fever occurred, lasting about one day, and attended by pain 
and distress in the epigastric region, but without vomiting or diarrhoea. 
In one of these the temperature was 103f°, the pulse 130 per minute. In 
the other case the temperature and pulse did not seem to be under these 
figures, but were not accurately ascertained. Occasionally the febrile 
movement is due more to complications than to the primary disease. 
Thus, in two of my patients the febrile movement was mainly attributable 
to diphtheritic inflammation which had attacked the fauces. But while 
the fever in rotheln is ordinarily of short duration, in certain patients tem- 
porary exacerbations may occur in which the temperature is as high as in 
scarlet fever or measles. 

Complications — Prognosis. — The only complication which occurred in 
cases in my practice has already been alluded to, namely diphtheria, 
which, when prevalent, is apt to attack surfaces already inflamed. In 
the Foundling Asylum varicella complicated one case and pneumonia an- 
other. In a third pneumonia occurred about three days after the disap- 
pearance of the eruption. The prognosis in uncomplicated cases is always 
very favorable, and there is no liability to sequelae more than in mild 
catarrhal inflammations of a non-specific character. The duration of 
rotheln is short, not ordinarily extending beyond three to five days. 

Nature — Incubative Period — Contagiousness. — Is rotheln a distinct 
malady or one with which we are familiar, but the form and character of 



222 ROTHELN. 

which are modified by unusual meteorological conditions ? Is it roseola 
assuming at certain periods an. epidemic character, and appearing to be 
contagious ? Or is it at all times infectious, possessing a specific principle, 
and, like other infectious diseases, self-propagating ? Should it in noso- 
logical classification be placed among the non-contagious and local, or 
among the constitutional and infectious maladies ? Let us consider the 
facts observed in the New York epidemics. 

The first cases of rotheln in this city were often designated roseola 
by the physicians called to treat them, since they seemed to resemble 
more closely this disease than any other with which they were familiar. 
But rotheln differs widely from the peculiar form of dermatitis known as 
roseola. The successive occurrence of the eruption over the upper and 
then the lower parts of the body, but covering the whole surface, and the 
definite duration of three to five days, are points of difference. More- 
over, roseola would not without so great change in its character as to 
become virtually a distinct disease, occur in the cool months without any 
appreciable dietetic cause, as an epidemic over a certain area and for a 
limited time, affecting whole households and sparing other households, 
as well as individuals of a certain age. We, therefore, consider it dis- 
tinct from roseola. 

Most of the cases in the New York epidemics bore considerable resem- 
blance to measles, both as regards the appearance and duration of the erup- 
tion and the catarrh of the mucous surfaces. Parents often diagnosticated 
measles before the arrival of the physician, and the physician himself, at 
first glance, sometimes made the same diagnosis. But in rotheln the 
shortness and mildness of the stage of invasion, the absence of cough or 
the presence of one trivial and scarcely noticed, appetite good or but 
slightly impaired, in fine symptoms that are transient or slight, afford a 
striking contrast to the graver symptoms of measles. But the decisive 
proof that rotheln is not a modified measles is found in the fact that one 
does not prevent the other. Of the forty-eight cases observed by myself, 
prior to May 1st, in the epidemic of 1874, nineteen at least had had 
measles, and one who had rotheln took measles subsequently. I have already 
stated that in the New York Foundling Asylum rotheln in 1873 and 
1874 closely followed an epidemic of measles. A considerable number of 
the children attacked by the former disease had recently recovered from 
the latter. During the epidemic of 1880 and 1881 the same fact was 
observed, namely that a previous attack of measles as well as scarlet fever 
afforded no protection from rotheln. Dr. Chadbourne, the resident phy- 
sician, writes of the cases in the Foundling Asylum in 1880 and 1881 : 
' ' Eight children had rotheln who had had both scarlet fever and measles 
within six months under my observation, while certain others had had 
these diseases at some previous time. ' ' Of the cases observed by my- 
self in family practice in the same epidemic, it is stated in my notes that 



NATURE. 223 

ten had had measles. These statistics are sufficient to show that rotheln 
is a distinct disease from measles, however close the kinship. 

That rotheln is not a form of scarlet fever is evident from the fact that 
as regards at least the New York epidemics the rash was in most instances 
quite distinct from the scarlatinous efflorescence, occurring, as we have said, 
in small more or less circular points and patches. Moreover, as we have 
remarked above, there is in rotheln a slight febrile movement and general 
mildness of symptoms, which contrast with the high fever and other pro- 
nounced symptoms of scarlatina, or if there be considerable febrile move- 
ment its duration is brief. But the conclusive proof of an essential differ- 
ence between these two diseases is found in the fact already stated in 
reference to measles, that the attack of the one malady does not prevent 
the occurrence of the other. There are, it is true, cases in which it is 
difficult at first to make the differential diagnosis between rotheln and 
mild measles or mild scarlet fever, but when the course of the malady has 
been closely observed for three or four days, it w T ill rarely happen, I 
think, that we will be unable to make out its character. 

Those cases of an epidemic which arise when the causes or conditions 
from which it is developed are most strongly operative and which at this 
time are apt to be typical, obviously afford the best data for studying its 
nature. Such were the forty-eight cases which I saw in the epidemic of 
1873 and 1874 and the forty-two in that of 1880 and 1881. As regards 
the former epidemic, in thirteen of the twenty-one families embraced in 
my statistics, the first cases were children, who up to the time of the 
seizure were attending public and private schools, and in certain instances 
those who were nearly simultaneously attacked, living perhaps in streets 
widely separated, were attending the same school. During the epidemics 
of 1880 and 1881, the first patients in thirteen of the eighteen families 
in which rotheln occurred were school children between the ao;es of six 
and twelve years, and in most, if not all, the different schools which they 
attended, rotheln was at the time prevailing as an epidemic, as I ascer- 
tained on inquiry. It, therefore, seemed probable that these had con- 
tracted it from others in the schools. 

In both the New York epidemics during the time that rotheln was at 
its maximum prevalence, in most of the families containing two or more 
children the cases were multiple, not occurring simultaneously, but in suc- 
cession, as if the malady was contracted from those first affected. This 
is what we daily witness in the spread of exanthematic fevers. Thus in 
Mr. E.'s family, a girl attending one of the public schools took rotheln in 
the middle of December, 1873 ; the two remaining children sickened 
with it one week and two weeks later. A niece visiting in the family at 
the time when the first child was sick, but returning home to another 
street, also had the eruption on December 27th. Alice R., aged ten 
years, a frequent visitor at Mr. E.'s, living in the same street, and several 



224 ROTHELN. 

times exposed to his children during their illness, also took rotheln about 
January 4th. West Seventy-first Street, where these cases occurred, is 
thinly settled and suburban, and I could learn of no other cases in the 
vicinity. A child of Mr. P., aged five and a half years, had been in the 
habit of playing with two children two doors away who became affected 
with rotheln in the beginning of April, 1881. On April 14th he was sup- 
posed to have a mild coryza from taking cold, as he sneezed often, but in 
a few hours the efflorescence appeared. Four days subsequently, on the 
18th, an infant was affected in the same way, and thirteen days later 
another child in the family, aged twelve years. In a similar manner 
rotheln occurred in the families of two brothers living in adjoining houses 
in West Fifty-first Street. The first patient was a boy of twelve years. 
It appeared successively in the children of these two families until ten had 
been affected. In a family in West Forty-sixth street, the first case was 
a boy attending a school in which rotheln was prevalent. Within twenty 
days, namely, between March 31st and April 20th, four other children 
were attacked in succession. 

These facts and cases seem to demonstrate the contagiousness of rotheln, 
at least during the time in which the conditions are most favorable for its 
development, or during the time in which the epidemic influence is most 
pronounced. In the declining period of both the New York epidemics, 
the cases which I observed occurred for the most part singly, although 
there was no attempt to isolate the patients, so the contagious character, 
if present, must have been very slight. 

Rotheln is in my opinion an exanthematic fever feebly contagious. It 
resembles varicella in general mildness of symptoms, in the absence of 
dangerous complications or sequelae, and in the uniformly favorable prog- 
nosis, while its symptoms show a resemblance to measles and scarlet fever. 

If the above view be correct, rotheln must possess an incubative period 
which, in the cases observed in both epidemics, apparently varied between 
seven, or perhaps less than seven, and twenty-one days. Its incubation, 
therefore, resembles that of scarlet fever, which, as is well known, varies in 
different patients. In the cases which came under my notice, the incu- 
bative period, when it could be accurately ascertained, was more frequently 
about two weeks, than a longer or shorter period. The resident physi- 
cian of the New York Foundling Asylum, when the epidemic was prevail- 
ing in that institution, returned to his home in the State of Maine to a 
locality where rotheln was unknown. Fourteen days from the date of his 
departure he was himself affected with the disease in its typical form. No 
other case occurred at his home, where probably the atmospheric condi- 
tions were unfavorable. Minnie B., attending a school in which there 
were many cases, had the rash on April 5th. On the 23d of the same 
month, eighteen days afterward, it appeared upon the servant who was 
frequently in Minnie's room. Elizabeth C, attending a school in which 



VARIOLA. 225 

rotheln was prevailing, had the eruption on April 17 th. It commenced 
upon her sister thirteen days, and upon her mother fourteen days subse- 
quently. 

Other cases might be cited of an apparently shorter as well as longer in- 
cubative period. The following note from Dr. Chadbourne, of the New 
York Foundling Asylum, bearing upon this subject, is interesting : " I am 
led to believe from my observations that the period of incubation was, in 
the majority of the cases, from twelve to fifteen days. The disease has 
been very feebly contagious. In some cases one child would have rotheln 
while the other, nursed by the same woman, would escape. In two in- 
stances women had the disease, and though each suckled two infants the 
latter escaped." 

Rotheln requires no treatment. 



CIIAPTEK IV. 

VARIOLA— VARIOLOID. 

Variola, or smallpox, is a specific febrile affection, accompanied by 
a vesiculo-pustular eruption of the skin. Since the discovery of the pro- 
tective power of vaccination it has been shorn of much of its terror, but 
it is still the most loathsome and most dreaded of all the fevers. Two 
forms of this disease are recognized, depending on the fact whether there 
have been previous vaccination. If the patient have been vaccinated at 
some period in his life, the disease, which is rendered milder in conse- 
quence, is designated varioloid. If there have been no vaccination, it is 
called variola or smallpox. Both forms are identical in nature, the one 
communicating the other ; they differ only in gravity. 

Smallpox presents four stages : the initial, or that of invasion ; the 
eruptive ; that of desiccation ; and, lastly, that of desquamation. It is 
called discrete when the pustules remain separated from each other ; con- 
fluent when they unite. This division is made according to the character 
of the eruption upon the face and hands. There are parts of the surface, 
as the abdomen, where the pustules are always discrete, even in the con- 
fluent form. 

Incubative Period. — During the last half of the last century inocu- 
lation with variolous matter was extensively practised in Great Britain 
and on the Continent, as it was found that smallpox thus communicated 
was milder than when received by infection. This operation enabled 
physicians to determine the period of incubation, which was found to be 
from eight to eleven days. When variola is communicated through the 



226 VARIOLA. 

air, the incubative period is somewhat longer, namely, from twelve to 
fourteen days. 

Stage of Invasion. — Smallpox begins abruptly with chilliness. In 
children of an advanced age there is often, as in the adult, a distinct 
chill. This is followed by fever and such symptoms as usually accom- 
pany febrile movement, namely, lassitude, anorexia, and thirst. In addi- 
tion certain symptoms arise which, though not peculiar to smallpox, are 
so marked in the commencement of this disease, that they possess con- 
siderable diagnostic value. These symptoms, which pertain to the nervous 
system and occur in the initial stage of varioloid as well as variola, are 
severe frontal headache, pain in the small of the back, and great drowsi- 
ness, sometimes with delirium. In many children convulsions occur, 
preceded and followed by a degree of stupor which is almost as profound 
as coma. Trousseau suggests the name rachialgia for the pain in the 
back, as he believes that it is located in or around the spinal cord. This 
belief is based on the fact which he, as well as other observers, has 
noticed, that there is sometimes in connection with this symptom an in- 
complete paraplegia, indicated by numbness of the legs, or even inability 
to use them, and sometimes more or less paralysis of the bladder. These 
paraplegic symptoms pass off in a few days. Vomiting is also a common 
symptom in this stage, and one also of diagnostic value. It occurs at 
short intervals for twenty -four to thirty-six hours. The same symptom is 
common in scarlet fever, and not infrequent in measles, but in both these 
maladies irritability of stomach is much less persistent than in smallpox , 
vomiting does not occur in normal rubeolous and scarlatinous cases more 
than once or twice. 

The tongue is covered with a moist fur. If the disease is to be dis- 
crete, constipation is commonly present in the stage of invasion ; if con- 
fluent, diarrhoea is a common symptom, continuing till the fourth or fifth 
day, or even longer. Roseola or erythema sometimes occurs in this 
stage, and this may lead to error of diagnosis, the disease being mistaken 
for one of these cutaneous affections, or even for scarlet fever. The 
symptoms in the stage of invasion are usually more violent in confluent 
than in discrete variola, but there are exceptions. 

Stage of Eruption. — The eruption commences about the third day, 
earlier in some cases, later in others. The average duration, therefore, 
of the first stage is somewhat shorter than in measles, but considerably 
longer than in scarlet fever. Sydenham has stated, and observations 
show the truth of the remark, that the shorter the first stage, the more 
severe the disease will prove to be ; and, conversely, the longer the 
period, the milder will be its form. Therefore, if the eruption begin on 
the second day, it will, as a rule, be confluent ; if not till the fifth or 
sixth day, it will be scanty and the disease light. 

The eruption commences in minute red spots, somewhat like those of 



STAGE OF ERUPTION. 227 

lichen, which gradually enlarge. It is first observed around the lips and 
upon the neck, then upon the face, scalp, upper part of chest, arms, and 
finally upon the lower part of the chest, the abdomen, and legs. It is 
sometimes, especially in young children, first observed in the folds of the 
skin, as about the genitals or in the groin. If the cuticle be irritated, as 
by a sinapism, the eruption often appears first upon this part of the sur- 
face and in greater abundance than elsewhere. Commencing in a 
minute reddish point, as stated above, it rapidly enlarges, and soon 
its central part begins to be indurated and raised. It feels round and 
hard to the finger, is tender, and its diameter does not ordinarily exceed 
two lines. This is the papular stage. The papulae increase and become 
more elevated, and in twenty-four to forty-eight hours from the com- 
mencement of the eruptive stage they become vesicular. On the fifth 
day of the eruption, or eighth of the disease, the vesicle has attained its 
full size. Its diameter is then about one fourth of an inch, and its eleva- 
tion is two or three lines. Its base is circular and indurated, and it is sur- 
rounded by a narrow zone of inflammation, indicated by redness and tender- 
ness of the skin. The pock commonly, as it passes from the papular to 
the vesicular stage, loses its acuminate form, and becomes depressed in 
the centre, but in most cases, mixed with the umbilicated vesicles, are 
some which remain acuminate. 

In proportion as the eruption becomes developed in discrete variola and 
in varioloid, the symptoms which accompanied the stage of invasion 
abate ; the fever, headache, pain in the back, and thirst cease, and the 
appetite returns. In the confluent form, the febrile action continues 
with little abatement. 

Simultaneously with the eruption upon the skin, an eruption also occurs 
upon the buccal and faucial surfaces, and often upon that of the air-pas- 
sages. It occurs sometimes, also, upon the conjunctiva, producing dan- 
gerous ophthalmia, and even ulceration, with loss of sight, and upon the 
mucous surface of the genital organs. The form which it presents upon 
mucous surfaces is somewhat different from that upon the skin. There is 
at first a deposit of fibrin, producing a small, round, grayish spot at the 
point of eruption — firm, slightly elevated, and covered, if not by the 
entire mucous membrane, at least by its epithelial layer. Ulceration soon 
occurs, as in ulcerous stomatitis, and, if the patient live, the reparative 
process succeeds, as in simple ulcers. The eruption upon mucous sur- 
faces increases considerably the suffering of the patient, in consequence 
of the tenderness of the ulcers ; and if its seat be the surface of the 
larynx or trachea, it may be the immediate cause of death, especially in 
young children, by obstructing respiration. 

The cutaneous eruption has been traced to the vesicular stage. On or 
about the fifth day of the eruptive period, or eighth of smallpox, the 
vesicles gradually change their character, their contents becoming thicker 



228 VARIOLA. 

and turbid. At the same time they increase still more in size, and the 
central depression disappears. This is designated the stage of matura- 
tion, or of suppuration, though it is known that the turbidity is due 
chiefly to another substance than pus. The pock having undergone these 
changes, is termed the pustule. 

In discrete variola, and in varioloid, the fever returns during the pustu- 
lar stage ; or, if the form of the disease be confluent, and the fever have 
continued, it now becomes more intense. The return of fever, or its 
increase, is denoted by increased frequency of pulse, elevation of tem- 
perature, dryness of skin, anorexia, and thirst. A tendency to consti- 
pation remains throughout in varioloid and discrete variola; in the con- 
fluent form diarrhoea more frequently occurs, which, if it continue, is 
an unfavorable prognostic sign. 

Other changes occur. The pustules increase somewhat in size, and 
become more globular. Some of them, when most distended, break 
through friction of the clothes, or scratching of the child, and, their con- 
tents escaping, add to the loathsomeness of the disease. There is in the 
pustular stage more or less redness of the surface between the eruptions, 
and, except in the mildest cases, tumefaction from subcutaneous infiltra- 
tion occurs. In the confluent form, at this period, the features are often 
so swollen that the friends would not recognize the patient. The eyelids 
may be so oedematous that the eyes are for a time concealed from view. 
This oedema of the surface is not altogether absent in the vesicular stage, 
but it increases during the time of maturation, after which it subsides. 

Stage of Desiccation. — This immediately succeeds the full develop- 
ment of the pustules. The liquid portion of the contents of the pustules, 
which are broken, evaporates, leaving a crust. If there be no rupture, the 
liquid is absorbed and a scab results, which, though smaller, preserves in 
a measure the form of the pustule. While the pustule desiccates, the sur- 
rounding inflammation rapidly abates. The crusts occur first upon the 
face, and on other parts in the order in which the eruption appeared. 
The odor from the patient, at this time, is peculiar. In the confluent 
form, especially, it is very offensive, and can be noticed at a distance 
from the bedside. Rilliet and Barthez call it nauseous and fetid. As 
desiccation progresses, the symptoms, local and general, abate. The 
pulse and temperature, if the case be favorable, return to their normal 
standard. The cough, hoarseness, and thirst disappear, while the appe- 
tite returns ; the sleep is more tranquil, and the functions, generally, are 
more regularly performed. 

The last stage is that of desquamation ; it commences between the 
eleventh and sixteenth days. The scabs, which present a dark or brown- 
ish appearance, are successively detached. This period lasts several 
days ; sometimes two or three weeks even elapse before all the crusts sep- 
arate. In the mean time the patient gradually recovers his health and 



VARIOLOID. 229 

former strength. After the fall of the crust, the cicatrix underneath pre- 
sents a reddish appearance. This color gradually fades, and there 
remains an irregular depression, or pit, of a lighter color than the sur- 
rounding surface; and if there have been a full development of the erup- 
tion, disfiguring the patient for life. 

Such is the clinical history of variola, when it is favorable, and its 
course is regular. The disease is sometimes irregular. In rare instances 
the eruption occurs almost at the commencement of the attack. The 
form is then very apt to be confluent. There are irregularities, also, in 
consequence of diarrhoea, haemorrhages, or other complications. I have 
known the eruption appear first on the limbs, and last on the trunk and 
face, and the appearance of the eruption is not always the same. In the 
anaemic and feeble child it often presents a pale color, with some indura- 
tion at its base, but without the red areola around it, or with this quite 
indistinct. In rare instances the vesicles have a reddish color, their con- 
tents being tinged with blood. This form of variola is designated hemor- 
rhagic. It indicates a profoundly altered state of the blood. The erup- 
tion in this form is of small size, and if the pock be broken, blood oozes 
from it. 

I have met one, perhaps two cases of malignant hemorrhagic small- 
pox, as described by Hebra, among the rare forms of this malady. The 
second case died so soon that we were undecided whether he had small- 
pox or scarlatina. A man aged 36 years, previously healthy, became 
suddenly and severely sick, in June, 1881, with fever, intense headache 
and backache, great depression of the vital powers, sleeplessness, and a 
sensation of sinking or depression in the epigastrium. He had a marked 
foreboding of coming evil, and begged almost constantly for relief. 
Within forty-eight hours a heavy and continuous dusky scarlatiniform 
eruption covered the whole surface, except below the knees, disappearing 
on pressure ; fauces at first but moderately injected. On the following 
day, the third of his sickness, with a temperature of 104.5°, the efflor- 
escence became a dark red, numerous small extravasations of blood had 
occurred under the skin, the urine contained blood, and finally seemed to 
consist almost entirely of dark blood; a large effusion of blood under the 
entire conjunctiva of either eye prevented closure of the eyelids, and 
probably haemorrhages had occurred within the eyes, as the sight was. 
nearly lost. Death occurred on the following day. In Hebra' s article on 
smallpox is the description of precisely such cases, but the death of my 
patient was too early for exact diagnosis. 

Varioloid. — The course of varioloid is similar to that of variola, but 
it is somewhat shorter. It commences with rigors, followed by fever, 
headache, pain in the back, vomiting, drowsiness, and sometimes delirium, 
or even convulsions. The symptoms in the stage of invasion are, indeed, 
the same in character, and often nearly as severe as in variola. With the 



230 VARIOLOID. 

initial symptoms, there is also sometimes a scarlatiniform eruption, so that 
the disease may at first be mistaken for scarlatina. On the third or 
fourth day the variolous eruption commences. The number of pocks is 
commonly few, often not more than twelve to twenty. In the mildest 
form of varioloid, if the physician be not summoned in the stage of inva- 
sion, he is not apt to be called at all, so that the patient may pass through 
the disease in ignorance of its nature. The true character of the malady 
is not ascertained till others are affected, either with variola or vario- 
loid. 

The eruption pursues a more rapid course in varioloid than in the un- 
modified disease. By the fifth or sixth day the pustules are fully devel- 
oped, though often smaller and less likely to be ruptured than in variola. 
Often, in varioloid, the eruption aborts. It remains papular two or three 
days, and then declines, or it may reach the vesicular stage, and decline 
without pustulation. 

The constitutional symptoms in varioloid abate with the commencement 
of the eruptive stage. The secondary fever is slight or absent. 

Such is the usual mild course of varioloid, but not always. If several 
years have elapsed since the vaccination, its protective power is greatly 
impaired, and varioloid may then exhibit as severe a form as ordinary 
smallpox. In some instances it is fatal. 

The term varioloid is, as has been stated, applied to cases of variolous 
disease if there have been previous vaccination. It is also applied by 
writers to second attacks, whether the first occurred from infection or 
from variolous inoculation, but such cases are rare. 

Mode of Death. — Death in smallpox occurs in several different ways. 
The most fatal period is the pustular. Feeble children not infre- 
quently die from exhaustion at or about the time that the pustules attain 
their greatest size. The eruption appears and becomes developed as, 
usual, but there are evidences of weakness in the patient, and suddenly 
the progress of the vesicle or pustule ceases. It begins to subside, and its 
walls shrivel. There is evidently absorption, in part, of the liquid con- 
tents. These phenomena are of the gravest character. Death is the 
common result, and within twenty-four hours. In other cases death 
occurs from apncea. The pock increasing in size in the larynx and tra- 
chea, obstructs inspiration, or there may be the formation of a pseudo- 
membrane, as in true croup. This is not an unusual mode of death in 
young children, in whom the calibre of the larynx and trachea is small. 
Sometimes convulsions and coma occur in the last hours of life. In other 
cases the stage of desquamation is reached, but convalescence does not 
occur. The patient each day becomes more anaemic and feeble, and 
finally death results from failure of the vital powers. Again, after small- 
pox has run its course, purpura hemorrhagica may be developed. Haemor- 
rhages occur from the gums, throat, nostrils. Blood is vomited, and 



COMPLICATIONS. 231 

evacuated in the stools. I have known death to occur in all these ways, 
but that from purpura is least frequent. Sometimes, as in scarlet fever, 
death occurs suddenly and unexpectedly in confluent, and even in discrete 
variola, when the previous symptoms had apparently been favorable. 
The patient is overpowered by the intensity of the virus. 

Anatomical Characters. — In those who have died of variola, with- 
out inflammatory or other complication, the heart-clots have been found 
small, dark, and soft. The blood is dark and thin. The vessels of the 
brain and its membranes are injected, so that numerous red points appear 
on the cut surface of this organ. The vessels of the lungs and the ab- 
dominal organs are congested, while the muscles present a deep red color. 
The variolous eruption penetrates more deeply than that of any other 
exanthematic fever. It has been stated elsewhere that it occurs not only 
on the skin, but often on the surface of the mouth, fauces, and air-pas- 
sages. The mucous membrane in these situations is frequently also the 
seat of catarrhal inflammation, being thickened and softened, and in some 
parts, as the larynx, a pseudo-membrane is occasionally produced, as in 
croup. The inflammation, whether catarrhal or pseudo-membranous, may 
occur without as well as with the presence of the specific eruption. 

The eruption very seldom, perhaps never, appears upon the gastro -intes- 
tinal surface, but the solitary follicles and patches of Peyer are often en- 
larged, as in some other zymotic affections. The liver, spleen, and kidneys 
are commonly congested in those who have died of variola. The spleen, 
especially, is increased in volume and softened ; the kidneys are enlarged, 
as if from commencing nephritis, and sometimes softened. 

The minute structure of the pock is described by Rilliet and Barthez, 
and others. The vesicle is multilocular, consisting of at least five or six 
compartments, with distinct partitions. Its centre is united by fibrous 
bands to the derm beneath, which union gives rise to the umbilicated ap- 
pearance. The giving way of these minute bands in the pustular stage 
occurs when the form changes from the umbilicated to the convex. In 
the pustular stage also, according to some, a fibrinous formation occurs 
within the pustule ; according to others, this substance is of the nature of 
the epidermis, presenting the appearance of the cuticle when macerated. 
Mixed with this epidermic or fibrinous formation are pus-cells. 

Complications. — There are several different complications of variola. 
One is salivation. This is common in the adult, but rare in the child. 
When it occurs in the child, it is slight, commencing with or about the 
time of the eruption, and disappearing in from one to four or five days. 
Ophthalmia is another complication. Simple conjunctivitis, often quite 
intense, may occur in consequence of pustules developed under the lids. 
This inflammation subsides without injury to the eye, as the primary dis- 
ease abates. A more serious inflammation occurs at an advanced stage 
of variola, commencing in or near the desquamative period. This 



232 VARIOLOID. 

produces more or less chemosis, and sometimes opacity or ulceration of 
the cornea. A similar inflammation may occur in the ear, giving rise to 
otorrhoea, and even in some patients, to rupture of the drum of the ear. 
Abscesses in the subcutaneous connective tissue have been occasionally ob- 
served, especially in the confluent form. Subcutaneous infiltration and 
feebleness of constitution favor their occurrence. Suppuration within the 
joints is a somewhat rare complication or sequel, rendering convalescence 
protracted, if, indeed, the case be not fatal. 

M. Beraud has published a memoir to show that orchitis in the male 
and ovaritis in the female may complicate variola. These inflammations 
are believed to be accompanied by a small and imperfect variolous erup- 
tion upon the tunica vaginalis and the peritoneal covering of the ovary. 
Trousseau states that he has often met this complication in the male, since 
his attention was called to it. It is mild, and subsides with the disappear- 
ance of the eruption. Laryngitis, simple or diphtheritic, bronchitis, pneu- 
monia, pharyngitis, purpuric haemorrhages, gangrene of the mouth or 
other parts, oedema pulmonum, and oedema glottidis are occasional com- 
plications, some of which are frequent, others rare. 

Prognosis. — This depends on the age, vigor of system, form of the 
disease, and the presence or absence of complications. The younger the 
child, the greater the danger. Trousseau says : " Confluent variola, and 
even discrete variola, are almost always fatal in individuals less than two 
years old." Above the age of three or four years discrete variola usually 
ends favorably, but the confluent form is still, as a rule, fatal. Varioloid 
in the child is a mild disease, terminating favorably in a large proportion 
of cases. It is milder at this age than in the adult, on account of the 
more recent period of vaccination. If varioloid be severe, and the erup- 
tion abundant in a child who has been vaccinated, it is probable that the 
vaccination was spurious. 

It is not necessary, from what has been said, to specify the favorable 
prognostic signs. The unfavorable prognostics are, great violence of the 
initial symptoms ; early appearance of the eruption ; an abundant erup- 
tion, especially if pale, and without swelling of the surface ; rapid decline 
of the eruption in the vesicular or pustular stage ; haemorrhagic eruption, 
or haemorrhages from the surfaces ; fever continuing after the appearance 
of the eruption ; diarrhoea persisting beyond the third or fourth day ; 
delirium or great drowsiness ; a frequent and feeble pulse ; and, finally, 
obstructed respiration — if slow, indicating a pseudo-membrane or variolous 
eruption in the larynx or trachea ; if rapid, indicating bronchitis or 
pneumonia. 

Diagnosis. — The diagnosis cannot be made with certainty prior to the 
eruptive stage. If, however, smallpox be prevalent, if the patient have not 
been vaccinated, and the symptoms which pertain to the period of inva- 
sion be present, as headache, pain in small of back, repeated vomiting,. 



TREATMENT. 233 

drowsiness, and perhaps convulsions, there is ground for the gravest sus- 
picion. If, in addition to these symptoms, reddish points begin to appear 
on the second or third day, the diagnosis may be made with confidence. 
At this early period, even before there is any distinct cutaneous eruption, 
ash-colored spots may sometimes be observed on the buccal or faucial 
surface, the commencement of the variolous eruption ; these possess con- 
siderable diagnostic value. 

The scarlatiniform efflorescence, in the first stage of variola, sometimes 
leads to the belief that the disease is scarlet fever. The absence of the 
pharyngitis, and the appearance of the variolous eruption soon after the 
efflorescence, correct the diagnosis. Smallpox has, in the beginning of the 
eruptive period, sometimes been mistaken for measles. The points in- 
volved in the differential diagnosis have been presented in treating of that 
disease. After the development of the eruption, it may be mistaken for 
varicella. The eruption of varicella is, however, preceded by symptoms 
which are milder and of shorter duration, and its appearance is different. 
It is irregular, instead of round ; is not umbilicated, and it does not have 
the round, inflamed, and indurated base, which characterizes the variolous 
eruption. The eruption of ecthyma is sometimes umbilicated, but the 
symptoms of ecthyma and variola, and the progress of the eruptions in 
the two diseases, are very different. 

Treatment. — Smallpox, like the other essential fevers, is self-limited, 
and therefore the constitutional treatment should be sustaining and pallia- 
tive. In the first stages of the disease, the diet should be simple ; gentle 
laxatives and refrigerant drinks are required if there be much febrile ex- 
citement. Lemonade is a grateful drink, and may be given in moderate 
quantity. Spiritus Mindereri in carbonic acid water may be allowed. As 
the disease advances, more nutritious food should be recommended ; and 
in severe cases carbonate of ammonium, and even alcoholic stimulants, are 
required. 

As confluent smallpox is nearly always, and the discrete form often fatal 
in infancy, the physician should carefully watch the progress of the case 
in the infant. By judicious treatment, some, in this period of life, may 
be saved, who otherwise would perish. In the infant depressing measures 
should be avoided. A laxative may be given, at first, if there be much 
fever, and the bowels are constipated ; but the diet should be nutritious, 
and many soon require tonics and stimulants. If the pulse become more 
frequent and feeble, or if, with frequency of the pulse, the face and 
extremities become cool ; or, in the vesicular or pustular stage, the 
eruption suddenly subside, alcoholic stimulants must be immediately em- 
ployed, or the patient dies. 

Such is an outline of the constitutional treatment required in smallpox. 
Sydenham inculcated a mode of treatment which experience has shown to 
be injurious in infancy and childhood. He had observed that the severity 



234 VARIOLOID. 

of the disease was ordinarily proportionate to the amount of eruption, and 
concluded from this fact that measures which retarded the development of 
the eruption were salutary ; cold drinks, a cold apartment, scanty covering 
of the body, cathartics that caused derivation of blood from the surface, 
even sometimes the abstraction of blood, were considered, according to 
Sydenham's theory, to be useful as means of preventing full development 
of the eruption. 

Sydenham's treatment, however appropriate it might sometimes be in 
case of robust adults, is unsuitable for children, because they do not, as a 
rule, tolerate, in this disease, measures which reduce the strength. More- 
over smallpox is rendered more dangerous by what Rilliet and Barthez 
designate perturbating treatment — treatment which renders it abnormal. 
The regular appearance and development of the eruption are requisite in 
order that the case may progress favorably. On the other hand, the op- 
posite plan of treatment, which families, if left to themselves, are apt to 
adopt — namely the employment of measures to promote perspiration, as 
hot drinks, and confinement in a heated room — is also injurious. 

The patient should be kept in a temperature such as he has been accus- 
tomed to, and such as is agreeable to him ; his diet should be simple and 
nutritious ; laxative medicine should only be given to procure the natural 
evacuations. In smallpox, as in all infectious diseases, free ventilation 
of the apartment is required. 

"While the general eruption should not, as a rule, be interfered with, 
it is proper to endeavor to diminish, so far as possible the size of the pocks, 
on parts exposed to view, so as to prevent disfigurement. Professor Flint, 
in his Treatise on the Practice of Medicine, has published an excellent 
summary of the various measures which have been recommended for ac- 
complishing this end. First : The opening and breaking up of the vesicle 
by means of a fine needle. This is tedious practice in confluent variola, 
but it can readily be performed in the discrete form — at least as regards 
the vesicles upon the face. This treatment was proposed by Rayer, and 
it is recommended by many who have tried it. Secondly : After the 
evacuation of the liquid, the cauterization of the vesicle by a pointed stick 
of nitrate of silver. Rilliet and Barthez say, in reference to this mode of 
treatment, ' ' Individual cauterization of the pustules is, on the other hand, 
an almost infallible means of causing them to abort. To be successful, it 
is necessary to penetrate into the interior of the pustule with a pointed 
crayon of nitrate of silver in order to cauterize the derm. . . . It is 
only the first or second day of the eruption that it (cauterization) has cer- 
tain success ; nevertheless, we have often seen it succeed the third or the 
fourth day ? or even the fifth." 

Thirdly : The application of tincture of iodine once or twice daily over 
the eruption when in the papular stage. Some writers, who have em- 
ployed iodine, state that it does not prevent pitting but diminishes it. Its 



TREATMENT. 235 

favorable effects are produced by coagulating the contents of the papule. 
Fourthly : The exclusion of light and air by means of a plaster. A mix- 
ture containing tannate of iron has been employed for this purpose in one 
of our hospitals. This produces a black mask. Light and air may also 
be excluded by smearing the face with sweet oil, and dusting twice daily 
upon the oiled surface a powder containing equal parts of subnitrate of bis- 
muth and prepared chalk. Fifthly : The application of mild mercurial 
ointment upon the face or other parts of the surface, where it is desirable 
to render the eruption abortive. This mode of treatment does diminish 
the size of the vesicles and the pitting, but I should not recommend it for 
children. I have known in the adult severe mercurialization from its em- 
ployment for four or five days, and, though young children do not exhibit 
so readily the effects of mercury, the use of the ointment, unless for a very 
limited period, increases, in my opinion, their feebleness, and diminishes 
the chance of their recovery. Calamine made into a paste with sweet oil 
is said to be equally effectual with mercurial ointment, and it produces no 
constitutional effect. Its effect is obviously similar to that of the bismuth 
and chalk employed with sweet oil as stated above. Also, I have em- 
ployed pulverized charcoal made into a thin paste with sweet oil or glyce- 
rine, and applied daily or twice daily to the face. It effectually excludes 
the light, and the result appeared to be good as regards pitting, but it is a 
disagreeable application. Curschmann recommends as preferable to any of 
these methods, the use of iced compresses to the face and hands. The 
pain, redness, and swelling are diminished by their use, but without 
change in the copiousness of the eruption. (Ziemssen's Encyclop.) If 
fissures or excoriations occur, an application may be made of oxide or 
carbonate of zine in glycerine, one drachm to the ounce. 

The prevention of smallpox, so far as practicable, is one of the import- 
ant incidental duties of the physician. Isolation of the patient, and pre- 
cautions in reference to his clothes and bedding, are imperatively required, 
so great is the contagiousness of this disease. The only certain means of 
prevention is confessedly vaccination, and providentially the incubative 
period of the vaccine disease is much less than that of variola. Therefore, 
smallpox may be prevented after the virus is received in the system, by 
timely and successful vaccination. Vaccination, at any period between 
the time of exposure and the commencement of the symptoms of invasion, 
will either prevent the occurrence of smallpox or modify it. If the symp- 
toms of invasion have already commenced, it is uncertain whether it pro- 
duces any modifying effect. 



236 VACCINIA. 



CHAPTER Y. 

VACCINIA. 

Vaccinia is a mild eruptive disease, which occasionally occurs among 
cattle, and has been propagated from them to man. It is characterized 
by the appearance upon the surface of one or more papules, which soon 
become vesicular, and then pustular. It is communicable by contact, but 
unlike the other eruptive fevers, it is not contagious through the air. It 
is inoculable, both by the liquid contained in the vesicle, which is desig- 
nated vaccine lymph, and by the scab which results from the desiccation 
of the pustule. 

To Gloucestershire, England, the honor belongs of discovering and 
utilizing the fact that vaccinia, a mild and comparatively harmless 
disease, is transmissible from the cow to man, and that it affords protec- 
tion from smallpox. It appears that a vague opinion prevailed among the 
farmers of this dairying section, that a disease, which has since been des- 
ignated vaccinia, was occasionally received from the cow in milking, the 
virus passing from a pustule on the teat to a sore or chap on the hand of 
the milker, and that those who thus contract the disease receive immunity 
from smallpox. As usually happens with important discoveries, so slow of 
apprehension is the human intellect, these people, to whom Providence had 
revealed a most important fact, were blind to its real value. Finally, in the 
year 1774, Benjamin Jesty, whom the world has not sufficiently honored, 
" an honest and upright man," according to his epitaph, a farmer of Glou- 
cestershire, had the courage to vaccinate his wife and two children. His 
excellent moral character did not shield him. He was regarded by his 
neighbors as an inhuman brute, who had performed an experiment on his 
own family, the tendency of which might be to transform them into 
beasts with horns. 

This first essay in vaccination appears to have been entirely successful, 
but the prejudice against the operation continued. A fifth of a century 
passed, during which there was no extension of the benefits of this great 
discovery. At last, toward the close of the last century, Dr. Edward 
Jenner, a physician of Gloucestershire, and inoculator of his district, began 
to investigate this disease of the cow, about which little was known, and 
the grounds for the belief that it afforded protection from smallpox. For- 
tunately for the world, Jenner had been educated under John Hunter, 
and had learned from his great master to study nature rather than books, 



VACCINIA. 237 

to be guided by experience and observation rather than by the dogmas 
of his predecessors or of the schools. 

Jenner performed his first vaccination on the 14th of May, 1796, twenty- 
two years after Benjamin Jesty had lost his good name among his neigh- 
bors for vaccinating his own family. The popularizing of vaccination, 
mainly through Jenner's perseverance, affords one of the most interesting 
and instructive chapters in the history of medical science. How he went 
up to London, full of the importance of the discovery, and was there 
advised by his medical friends to desist from his wild schemes, lest he 
should injure the reputation which he had gained from a creditable paper 
on the habits of the cuckoo ; how he w T as finally allowed to vaccinate in 
hospital Awards, and gained some adherents to the new faith among the 
leading physicians of the metropolis ; and, finally, how, as the claims of 
vaccination began to be recognized, at the close of the last century and com- 
mencement of the present, a most acrimonious discussion arose, which 
filled all the medical journals of that period. The opponents of vaccina- 
tion resorted to every device to prevent the acceptance of Jenner's views. 
They attempted to prejudice the people against them by specious argu- 
ments, by ridicule, and even by caricatures. One of the leading journals 
contained the picture of a cow covered with sores, and devouring children, 
and it was urged that vaccination was a bestial operation, degrading man 
to the level of the brute. But the truth had gained a firm hold, and the 
practice of vaccination extended. 

The discovery of vaccinia, and of its protective power, cannot be too 
highly appreciated. It has, probably, done more to relieve human suffer- 
ing than any other discovery of the last one hundred years, unless we 
except that of anaesthetics, and more to save human life than any other 
instrumentality of a purely physical kind. 

The fact was established in the time of Jenner that the virus of small- 
pox inoculated in the cow produced vaccinia, which, in its propagation 
back to man never returned to its original form, but always remained vac- 
cinia. Moreover, Jenner believed that the disease known in the horse as 
the grease was identical in nature with vaccinia in the cow. He failed, 
however, in his experiments to communicate vaccinia from the horse, but 
other experiments have been more successful. In 1801, a Dr. Loy, of 
the county of York, England, met two cases of vaccinia in persons who 
had taken care of a horse affected with the grease, and, from the lymph 
which he obtained, w r as able to produce vaccinia in the cow. In 1805, 
Viborg, a Danish veterinary surgeon, after many failures, succeeded also 
in communicating vaccinia to the cow by means of the virus taken from a 
horse. 

From this time little light was thrown on this subject till within the last 
twenty years. Although Loy and Viborg, and perhaps a few others, had 
recorded their success, other experimenters had failed to communicate vac- 



238 VACCINIA. 

cinia from the horse. In the absence of additional cases the profession 
began to question whether there might not have been some error in the 
observations of the gentlemen whose names I have mentioned, and 
whether a disease identical with vaccinia occurred in the horse, or a dis- 
ease which might communicate vaccinia to the cow or to man, was still 
regarded as undetermined. 

Observations confirmatory of those of Loy and Viborg were at length, 
however, made, which must be regarded as conclusive. In 1856 in the 
department of L'Eure-et-Loir, France, M. Pichot was consulted by a boy 
who had on the back of his hands vaccine pustules, which had apparently 
reached the eight or ninth day. He had not taken care of nor been in 
contact with a cow, but had a few days before taken care of a horse 
affected with the grease. Vaccination was performed by means of the 
lymph taken from these pustules, and genuine vaccinia was produced. 

Again in 1860, an epidemic prevailed among the horses in Riemes and 
Toulouse, France. A mare sickened with the disease, and there was swell- 
ing of the hough, with discharge of sanious matter. M. Delafosse vacci- 
nated two cows with this matter, and communicated genuine vaccinia. 
This epidemic was believed by the veterinary surgeons to be an eruptive 
fever, differing in its nature somewhat from the disease or diseases which 
have ordinarily been designated the grease. It has been conjectured that 
two or more distinct affections of the horse have the same appellation, one 
of which, it is now admitted, is identical with vaccinia of the cow, and 
may communicate it ; and the reason why so many experimenters have 
failed to vaccinate the cow from the horse is that they have used the virus 
of the wrong disease, or have taken matter from horses which had been 
affected with the true disease, but from ulcers which had lost their specific 
character. 

Prior to the time of Jenner variolous inoculation was practised in most 
civilized countries, since variola produced in this way was found to be 
milder than when arising from infection. This practice is now obsolete ; 
forbidden in some places by legislative enactments. It is superseded by 
vaccination. Vaccination, or the introduction of vaccine lymph into the 
system, is quickly and conveniently performed by scarifying with a lan- 
cet, and rubbing into the incisions the lymph, or a little of the scab pul- 
verized and dissolved in a drop of cold water. It may also be performed 
by scraping off the epidermis with the edge of the instrument till the 
blood begins to ooze ; and also, though with less certainty of success, by 
puncturing the skin with the point of the lancet, or by an instrument 
called the vaccinator. The scab should never be employed when it is 
possible to obtain pure lymph, since it contains animal matter apart from 
the virus, and may be the medium through which other diseases may be 
communicated. Besides it is much less active than pure lymph. 

If the child have a vascular naevus, this may be selected as the point of 



APPEARANCES — SYMPTOMS. 239 

vaccination. Unless of large size, it can usually be cured by the inflamma- 
tion which vaccinia produces. Statistics collected by Simon, as well as 
Marson, show that of those who contract varioloid, the larger the number 
of vaccine cicatrices the milder the disease, and the less the proportionate 
number of deaths. In Simon's statistics of those who stated that they had 
been vaccinated, but who presented no cicatrix, 21} per cent died ; of 
those who had one cicatrix, 7 J per cent died ; of those who had two, 4^ 
per cent died ; of those who had three, If per cent died ; while of those 
who had four or more cicatrices, only f per cent died. These statistics 
would seem to indicate the propriety of vaccinating in several places. But, 
so far as appears, when two or more cicatrices were observed, the patients 
may have been vaccinated at different times, at intervals, perhaps of seve- 
ral years, and if so, the inference would not follow that more complete pro- 
tection is produced by vaccinating in several places than in one. More- 
over, if vaccination be performed in the usual manner by several incisions 
on the arm, and the virus be fresh and active, usually two or more distinct 
vesicles arise, which unite in their development, and probably protect the 
system as much as if they were separated by a wider space. 

Appearances — Symptoms. — In genuine vaccination no effect is ob- 
served, except the slight inflammation due to the operation, till the close 
of the third day. Then the specific inflammation commences. This is 
indicated by a small red point, at first scarcely visible, indurated and 
slightly elevated, as determined by the touch, rather than by the eye. 
This increases, and on the fifth day the cuticle over the inflamed part 
begins to be raised by a transparent and thin liquid. The vesicle increases 
in diameter, and by the sixth day presents an umbilicated appearance, 
and is surrounded by a faint and narrow red zone. At the close of the 
eighth day the vesicle is fully developed. Its size varies considerably. 
It is usually from a sixth to a third of an inch in diameter, and oval or 
circular. If the vaccination have been performed by incisions, the size of 
the matured vesicle may be considerably larger, and its shape irregular, in 
consequence of the union of two or more vesicles. The eruption now pre- 
sents a whitish or pearl-colored appearance, due to the whiteness of the 
cuticle, and the transparence of the liquid underneath. If the vaccination 
be performed by incisions, it is not unusual to observe over the centre of 
the vesicle, and adhering to it, a small yellowish scab s which has resulted 
from the scarification, and which contains none of the virus. 

The vaccine vesicle, like that of variola, consists of compartments, com- 
monly eight or ten, with complete partitions, so that there is no intercom- 
munication. On the ninth day the inflamed areola becomes more distinct, 
and its diameter rapidly increases. Its color is deep red, its temperature 
is considerably elevated, and it is accompanied by more or less induration 
of the subcutaneous tissue, and it is tender to the touch. On the tenth 
day the pock has reached its full development. The areola then extends 



240 VACCINIA. 

from one to two inches away from the vesicle, becoming fainter at its outer 
circumference, and gradually disappearing in the healthy skin. The shape 
of the outer circumference of the areola is irregular, projecting further at 
one point than another, though its general form is circular. 

On the tenth day, when the inflammation has reached its maximum, the 
heat, itching, and tenderness in and around the pock are such that the 
child is often feverish and restless. Occasionally the glands of the axilla 
become swollen and tender. In other cases, in which there is but a mode- 
rate amount of inflammation, the constitutional disturbance is slight. 

At the close of the tenth day, or on the eleventh, the inflammation 
begins to decline ; the areola becomes narrower and then disappears ; the 
induration and tenderness abate ; and with this change the pustule desic- 
cates, its liquid is absorbed, and there results a brownish or a dark 
mahogany-colored scab, which is detached, ordinarily, between the four- 
teenth and twenty -first days. The cicatrix, at first reddish, like all recent 
cicatrices, gradually becomes paler, and remains whiter than the sur- 
rounding integument. It presents several minute depressions or pits, 
which indicate the genuineness of the vaccination. 

Anomalies, Complications, and Sequels. — The vesicle is often 
broken, accidentally, or by the nails of the child. If the top of the vesi- 
cle be destroyed, or most of the compartments be opened, the inflammation 
is commonly increased, considerable suppuration occurs, and there results 
a large, irregular, yellowish scab, consisting of the virus mixed with desic- 
cated pus. This scab is entirely unreliable, and unfit for the purpose of 
vaccination, though the protective power of the disease is not diminished 
by injury of the vesicle, even if it be totally destroyed. The cicatrix which 
results from extensive injury of the vesicle is apt to be large, and without 
the indented points which characterize the normal cicatrix. 

In rare cases when the inflammation which surrounds the vesicle is in- 
tense and deep seated, suppuration occurs in the subjacent connective tis- 
sue, giving rise to an abscess. This abscess is commonly of small size, but 
it increases the fretf ulness and constitutional disturbance which attend vac- 
cinia. This subcutaneous suppuration occurs most frequently in those who 
have a scrofulous or vitiated state of system. Inflammation of the lym- 
phatic glands of the axilla I have spoken of as not infrequent in vaccinia. 
This sometimes proceeds to suppuration, producing an unpleasant, though 
not serious, complication. 

It sometimes happens that vesicles appear in other parts besides the 
points where the virus was inserted. These supernumerary vesicles com- 
monly occur where the cuticle has been removed by scalds or injuries. 

Trousseau relates the case of an infant whom he had vaccinated. On 
the eleventh day he was astonished to find twenty-seven vaccine pustules 
on the face, trunk, and limbs. This infant had, however, before the vac- 
cination, a simple non-specific eruption over the whole body, and it was 



ANOMALIES, COMPLICATIONS, AND SEQUELS. 241 

believed that it had produced these vaccinations by transferring the lymph, 
with its nails, to the various parts where the cuticle was denuded. 

It is not unusual, also, to observe minute papules appearing on parts of 
the surface simultaneously with or soon after the vesicle, and in a few 
days declining. These seem to be abortive vaccine eruptions. 

One of the most serious complications is erysipelas. This may occur 
directly from the operation, or from the inflammation caused by the vesi- 
cle, when the virus possesses no deleterious property ; and, again, it may 
result from some unknown element in the virus. It may occur imme- 
diately after the operation, when it commonly prevents the working of 
the virus, or during the vesicular or pustular stage ; or, again, after desic- 
cation and separation of the scab. I have observed it at all these periods. 

Erysipelas, occurring as a complication of vaccinia, is invariably re- 
ferred by the friends to the virus employed, and the physician who has 
had the misfortune to vaccinate is often unjustly blamed. In many of 
these cases there was a strong predisposition to erysipelas at the time 
of the vaccination, and the operation or the inflammation which accom- 
panied the normal development of the vesicle served simply as an exciting 
cause. Erysipelas would occur as soon from a non-specific sore ; indeed, we 
not infrequently are called to cases of this disease in young children, which 
commence from non-specific sores upon the genitals, or on one of the 
limbs. That the fault is not in the virus employed, is evident from the 
fact that other children, vaccinated with the same, have simple uncom- 
plicated vaccinia. 

Sometimes, on the other hand, the cause of erysipelas, whatever it may 
be, exists in the virus. For further facts in reference to this subject, the 
reader is referred to our remarks on erysipelas. 

The fact is established by many observations that syphilis is communi- 
cable by vaccination. The symptoms of it may not appear till vaccinia 
has terminated, or for a little time subsequently, but it then constitutes a 
very serious sequel. A physician of this city, well known in this com- 
munity as skilful in the diagnosis and treatment of skin diseases, and 
therefore not likely to be mistaken as regards the nature of the diseases, 
states that he communicated syphilis to two infants by vaccinating with 
the same scab. Both had the characteristic syphilitic eruption. In 
January, 1868, an infant was brought to Prof. Alonzo Clark's clinique, 
in this city, having syphilitic rupia, which, in the opinion of the physi- 
cians present, was undoubtedly the result of vaccination. 

Trousseau relates the case of a young woman, eighteen years old, who 
was vaccinated with virus taken from an infant apparently in perfect 
health. The vaccination was unsuccessful ; but twenty-three days subse- 
quently his attention was called to an eruption which had appeared in 
two places on the woman's arm, corresponding with the points where the 
virus had been inserted. The eruption was that of ecthyma, which, by 



242 V A C C I N 1 A . 

the next examination, which was five days subsequently, had been trans- 
formed into rupia. The axillary lymphatic glands were tumefied and 
indolent, and finally roseola appeared, which removed all doubts as to the 
syphilitic character of the disease. There was syphilitic infection, which 
first manifested itself in the points where vaccination had been performed 
[Article de la Vaccine). It is not ascertained in Professor Clark's case, 
nor is it stated in Trousseau's, whether the lymph or scab was employed 
for vaccination. There can be little doubt that the pure lymph never 
communicates anything but vaccinia, and if by vaccination any other 
disease be imparted, a little blood has mingled with the lymph, or the scab 
has been employed. 

The vesicle in genuine vaccinia is sometimes very small, not having a 
diameter of more than two lines. Occasionally the development of the 
vesicle is retarded. It does not appear till two or three days later than 
the usual time, or even a longer period. 

Vaccinia is modified by certain diseases. It is arrested by measles and 
scarlet fever, pursuing its course after the subsidence of the exanthem. 
On the other hand, it sometimes modifies the paroxysmal cough of per- 
tussis, but only during the time when the pock is maturing. Eczematous 
eruptions occasionally occur after vaccinia, as they often do after the other 
eruptive fevers, or, if already present, they may be aggravated 

Subsequent Vaccinations, 

A second vaccination, performed prior to the ninth day after the first 
vaccination, is successful. A genuine vaccine eruption results, which is 
smaller the more advanced the primary disease. This second eruption 
overtakes the first. On the ninth day the susceptibility to vaccinia is in 
most cases, lost ; so that vaccination performed on the tenth, or subsequent 
days, is unsuccessful. 

As a rule, an acute contagious disease occurs only once in the same 
individual. Vaccinia is an exception. In most people, after a few years, 
it can be produced a second time ; and cases of a third or fourth success- 
ful vaccination, at intervals of a few years, are not uncommon. Now, 
subsequent cases of vaccinia differ from the first, which has been described 
above. The period of incubation is shorter, and the vesicular, pustular, 
and desiccative stages succeed each other more rapidly, so that the whole 
period of the disease is less. The variation from the appearance and 
course of the first vesicle is proportionate to the degree of protection 
which the first vaccination still affords, both as regards smallpox and 
vaccinia. If several years have elapsed since the first vaccination, and 
the protective power which it afforded is nearly lost, the second vaccinia 
differs but little from the first. If, on the other hand, the first vaccina- 
tion still afford nearly complete protection, the result of the second is 
slight ; the eruption is insignificant, lacking the characteristic appearance 



PKOTECTION FKOM VACCINATION. 243 

of the vaccine vesicle, resembling a common sore, and disappearing within 
a week. It is not accompanied by the inflamed areola, or any appreciable 
constitutional disturbance. 

Vaccination often produces no result. This is sometimes due to the 
fact that the lymph or scab employed is useless. It has spoiled by keep- 
ing, or never has been good. In other cases it is due to a lack of suscep- 
tibility in the person. Some take vaccinia with difficulty, and only after 
several vaccinations ; just as children, though fully exposed, often fail to 
take measles or scarlet fever, on account of a condition of the system 
which prevents the reception of the virus, or antagonizes and controls its 
action. In some instances, after vaccination, an eruption is produced, 
which may or may not be genuine ; but it immediately becomes purulent, 
and is soon broken. A large yellow, uneven scab results, having none of 
the appearance and containing little or none of the vaccine virus. This 
scab, as well as the liquid matter which preceded the formation of the 
scab, is utterly useless for the purpose of vaccination, and, if so employed, 
will probably cause a sore from its irritating effect, but not of a specific 
character. If, in place of the true vaccine vesicle, the eruption present 
the appearance which I have described, namely, that of a pustule, soon 
breaking and forming a large irregular, yellowish scab, the vaccinia — if 
it be correct so to designate it — must be considered spurious. A sore has 
been produced by the animal matter which was employed in the vaccina- 
tion along with the virus, which has modified the action of the virus, and 
probably has rendered it useless as a means of protection ; or there may 
have been no virus inserted with this animal matter. The physician should 
in such cases insist on a second vaccination. 

Cases like the above are of frequent occurrence, and the parents of the 
child are often satisfied with the result. They see an eruption following 
vaccination, accompanied by considerable inflammation, and leaving 
a cicatrix. Unless undeceived by the physician, they are apt to remain in 
the belief of the child's security, uutil, perhaps, it takes smallpox. Such 
cases, obviously, tend to diminish the confidence which the public should 
have in vaccination as a means of protection from smallpox, and on ac- 
count of their frequent occurrence it is important in every case that the 
physician should see the result of his vaccination. It has been proposed, as 
a means of determining the genuineness of vaccinia, to revaccinate when 
the eruption begins, and if the first be genuine, the second will overtake it. 
This is called Brice's test ; but it is not necessary, since the physician, 
familiar with the appearance of the true vesicle, can determine at once its 
genuineness by the sight. 

Protection from Vaccination— Re vaccination. 

It was believed by the early advocates of vaccination that the general 
performance of this operation would soon eradicate smallpox from the 



244 VACCINIA. 

community, so that it would be interesting only to the medical historian 
as a scourge of past ages. This result, however, is not achieved. As a 
rule, the greater the benefit of any measure designed to ameliorate the con- 
dition of mankind, the greater and more numerous are the obstacles which 
diminish its effectiveness. Science is full of examples of this. Fortu- 
nately these obstacles, as regards vaccination, are not such as to impair 
the confidence of physicians in its protective power, and it is not too 
much to expect that this simple operation will yet be the means of render- 
ing smallpox a disease almost unknown, unless in its modified form. 

Vaccination should be performed in the first year of life. In rural districts, 
where there is little danger of exposure to smallpox, it may be deferred 
till the age of ten or twelve months. In the city, on the other hand, where 
there is constant intercourse of people, and where contagious diseases are 
often contracted in ignorance of the time and place of exposure, an earlier 
vaccination is advisable. Some physicians recommend performance of 
the operation as early as the age of four to six weeks. The objection to 
this is, that if erysipelas occur, so young an infant is apt to perish from it, 
whereas an infant three or four months old ordinarily recovers. For this 
reason I believe that the most suitable age is about four months for the city 
infant, in ordinary times ; but if smallpox be epidemic, vaccination should 
be performed at an earlier age. I have vaccinated even the new-born 
infant when smallpox had broken out in adjoining apartments. 

Vaccinia usually extinguishes, for a time, the susceptibility to smallpox. 
According to M. Gintrac, varioloid does not occur within two years in those 
who have been vaccinated. It may, however, in exceptional instances, 
occur in a mild form within a few months after vaccination. The protec- 
tion afforded by vaccination gradually diminishes by time, but it does not 
probably, as a rule, cease entirely. Varioloid, however, occurring thirty 
or forty years after a successful vaccination, is apt to be severe, and it may 
even be fatal, showing that it has been but slightly modified. In other 
cases, even after so long an interval, the symptoms present a degree of 
mildness which indicates that the protective power of the vaccination is 
not entirely lost. 

If a second vaccination be practised soon after the scab from the first 
vaccination has fallen, it will usually produce no result, but in other cases 
it gives rise to a little redness, swelling, and induration, which show that 
vaccinia has been reproduced, though in a very mild and insignificant 
form. It is probable that in these cases varioloid might also occur by 
exposure, though with a mildness corresponding with that of the vaccinia. 
The longer the period after the first vaccination, the greater the number of 
those in whom a second vaccination is effective, and, as has already been 
stated, the greater also the liability to the variolous disease, until the sys- 
tem is protected by a second vaccination. A second vaccination should be 
performed about the sixth or eighth year, and a third between the fifteenth 



SELECTION OF VIRUS. 245 

and twentieth year. If smallpox be epidemic, it is proper to vaccinate 
all who have not been vaccinated within three or four years. 

Selection of Virus. 

The lymph is preferable to the scab for vaccination, provided that it 
can be obtained fresh. The scab is more easily preserved, and, therefore, 
if the lymph and the scab be old, the latter is to be preferred. The lymph 
should be taken on the fifth day, if the vesicle be sufficiently developed. 
It may also be taken on the sixth, seventh, or even eighth day, provided 
that the areola have not formed. The lymph of the fifth day acts with 
greater energy, though that of the sixth or seventh day is not much in- 
ferior. Lymph obtained after the formation of the areola is less efficient, 
though it may communicate the genuine disease. 

There is no mode of vaccination so reliable as the use of lymph, taken 
directly from the arm and immediately inserted — the arm to arm vacci- 
nation. Lymph can be preserved for a few days on a flattened surface of 
whalebone, or the segment of a quill, and if employed within a week, it 
will usually communicate vaccinia. Lymph may be preserved a longer 
period between two surfaces of glass, but the best way of preserving it is 
in capillary glass tubes. The end of the tube is placed within the vesicle, 
and the lymph ascends by capillary attraction. When a sufficient quan- 
tity is received, the ends are sealed, by holding them for a moment in a 
flame. Care is requisite in doing this, so as not to heat the lymph, as it 
is spoiled by a temperature much above the body. When the lymph is 
used, the ends of the tube are broken, and by blowing gently through it, 
a sufficient quantity is received on the point of a lancet. 

If the scab be genuine, it presents a dark-brown or mahogany color, and 
has a circular, oval, or at least a rounded form ; it is firm, or compact, and 
has a lustre. Soft, yellowish, and irregular scabs are not genuine, and 
those of a dull appearance, or without lustre, have usually spoiled in the 
keeping. The scab is best preserved in soft beeswax, which excludes the 
air, and it should be kept in a cool place. It is the belief of many that 
the vaccine virus gradually becomes weaker by passing successively through 
the human system (Condie, American Journal of the Medical Sciences, 
April, 1865), and that therefore different specimens of virus work with 
different energy, according to the degree of removal from the cow. To 
what extent this view is correct is not fully ascertained, but, certainly, if 
the virus employed continue to produce a small vesicle, attended only 
by a little inflammation, there is reason to believe that the protection 
which it imparts is less than that from virus which works with greater 
energy, and it should be exchanged for such. In New York we are able 
to obtain at any time lymph directly from the heifer. It has never passed 
through human blood, for the original lymph came from cattle in one of 



246 VARICELLA. 

the provinces of France, where vaccinia was prevailing epidemicallv. 
The popular objection to vaccination is obviated by the use of this lymph, 
but it works with great energy, producing a large pock, and a sore which 
is often a month in healing. I have found it very reliable, and prefer to 
use it in ordinary cases. 

CHAP TEE VI. 

VARICELLA. 

Varicella, chicken-pox, or swine-pox, is the shortest and mildest of the 
eruptive fevers. It is highly contagious, so that few children escape who 
are exposed to it. Its period of incubation is from fifteen to seventeen 
days. It is not inoculable, or at least those who have attempted to in- 
oculate with the lymph of varicella have failed. I endeavored to commu- 
nicate the disease in this way some years ago, but without result. It 
attacks the same individual but once, and it occurs as an epidemic. It 
has been thought by some to prevail most immediately before, during, or 
after epidemics of smallpox, and it has been conjectured that it is a 
modified form of variola, and hence its name, which signifies little variola. 
This idea is, however, entertained by few, and it is opposed by the follow- 
ing facts : Varicella may occur after variola, or variola after varicella, 
without any modification, and the two diseases are very dissimilar as 
regards gravity of symptoms and duration. The variolous disease, whether 
smallpox or varioloid, often occurs in the adult ; varicella, on the other 
hand, is a disease of infancy and childhood. I have seen one adult case, 
w T hich I recall to mind, and Professor Flint states that he has also observed 
it, but its occurence at this period of life is rare. Moreover, varicella and 
variola have been known to occur simultaneously in the same individual. 
Such a case was reported by M. Delpech, in a memoir published in 1845. 

Symptoms. — Varicella usually commences with such symptoms as usher 
in ordinary mild febrile attacks, namely, headache, languor, chilliness, 
and sometimes aching in the back and limbs. Fever supervenes, which 
is usually moderate, the pulse rising perhaps to 100 or 112, and the ther- 
mometer showing an increase of temperature, but less than occurs in the 
other eruptive fevers. These symptoms which precede the eruption are 
sometimes absent, or are so mild as to escape notice. The fever usually 
ceases on the second day, but it may return on the following night. The 
appetite is rarely lost, and most children continue, more or less, at their 
amusements. 

When the above symptoms have continued about twenty -four hours, the 
eruption appears first over the trunk and soon afterwards over the face and 
limbs. It consists of minute disseminated papules, which become vesicu- 
lar in the course of a few hours. The occurrence of the vesicular stage is 
nearly simultaneous on all parts of the surface. The vesicles lack the hard 



DIAGNOSIS. 247 

indurated base of the variolous eruption, though they are sometimes sur- 
rounded by a faint zone of redness. They differ also from the variolous 
eruption in the absence of umbilication, and in irregularity of shape. 
Some are small and acuminate, some hemispherical, and of medium size, 
and others oval or elongated, and of large size. The inflammation is quite 
superficial, not involving the subcutaneous tissue, and scarcely affecting 
the deepest layer of the skin. 

The vesicles vary in size from the diameter of half a line to that of even 
three lines. They occasionally give rise to slight itching. On the second 
day of the eruption, or third day of the disease, they are still fully de- 
veloped, their liquid contents being nearly transparent. At the close of 
this day the liquid begins to be somewhat cloudy, and its absorption 
commences. On the fourth day of the disease desiccation progresses rap- 
idly, and by the fifth the liquid has for the most part disappeared, and a 
scab results, small, thin, and of a yellowish-brown color. The scabs are 
soon detached, the redness which indicated their seat disappears, the epi- 
derm which had been raised and removed by the eruption is reproduced in 
its normal state, and in a few days all evidence of varicella is effaced. A 
cicatrix occasionally results, but it is due not to the simple varicellar erup- 
tion, but to a sore produced from the eruption by the scratching of the child. 

The number of vesicles varies considerably in different cases. They are 
never, so far as I have observed, confluent ; but they are sometimes so 
abundant in young children that, if the disease were variola, it would be 
called severe discrete. They occur also on the buccal and faucial surfaces, 
where they soon break, forming small ulcers. 

Diagnosis. — Obviously the only diseases with which varicella is liable 
to be confounded are such as present vesicles at some stage of their course. 
From the local vesicular eruptions this disease is diagnosticated by the 
fact that the vesicles appear on all parts of the surface. It is sometimes 
mistaken for variola or varioloid, or vice versa — a mistake very damaging 
to the reputation of the physician. The points of differential diagnosis are 
the symptoms of invasion — severe, and lasting three or four days in the 
one ; mild, and continuing only one day in the other — an eruption passing 
slowly through its stages from the papulae, to the pustulae, umbilicated, with 
circular, raised, and inflamed base, appearing first on the face and neck, 
and not till a day later on the legs, in the one disease ; while in the other 
the evolution, shape, and course of the eruption, as described above, are 
materially different. By proper attention to these distinctive features it is 
rarely difficult to diagnosticate the two diseases. 

The prognosis in varicella is always favorable. It does not, of itself, 
endanger life, nor seriously incommode the patient ; nor does it give rise 
to complications or sequelse. The treatment, therefore, is the simplest 
possible. Mild diet, and a laxative, may be prescribed during the febrile 
period ; but nothing further is required. 



SECTION III. 

NON-ERUPTIVE CONTAGIOUS DISEASES. 



CHAP TEE I. 

DIPHTHEBIA. 



Diphtheria is a disease of antiquity, dating back at least as far as the 
commencement of the Christian era. Aretaeus, at the close of the first 
century after Christ, described the Malum iEgyptiacum as a malady, 
which occurred chiefly among children, and was characterized by a white 
concretion, spreading over the tonsils, a fetid breath, and in some patients 
by a return of food through the nostrils, and by great dyspnoea, ending in 
suffocation. Since the commencement of the sixteenth century, numerous 
epidemics of it have been observed in Europe and America, and at the 
present time it is one of the most common and fatal epidemic maladies in 
both continents, while in many localities, especially in large cities, it is 
established as an endemic. 

Age. — Diphtheria is pre-eminently a disease of childhood, a large 
majority of the cases occurring between the ages of two and ten years. 
Under the age of one year the younger the child the less the liability to it,, 
and it rarely occurs prior to the fourth month. The age of the youngest 
patient in my practice, so far as I recollect, whose disease was undoubtedly 
diphtheria, was three months and a few days; but in one instance, I ob- 
served upon the fauces of an infant of six weeks, whose brother had just 
died of diphtheria, a few white specks, like grains of salt, over each tonsil,, 
which disappeared in three or four days, without the occurrence of any 
marked symptoms, by the application of a solution of chlorate of potassium. 
Certain physicians, having charge of maternity wards, have observed a 
disease, occurring in new-born infants, which bears some resemblance to 
diphtheria, but which, if it be true diphtheria, presents anomalous features. 
Thus, Dr. W. S. Bigelow reports in the Bost. Med. and Surg. Journ. for 
March 11, 18*75, ten cases, occurring between September and December, 
1873, in the Boston Lying-in Asylum, all fatal but two. The prominent 
symptoms and anatomical characters were : dark hue of skin, hematuria, 
pseudo-membranous exudation upon certain mucous surfaces, dark green 
stools, spleen enlarged and dark, kidneys engorged, and in some of the 



INCUBATION. 249 

cases effusion of blood into the pelves of these organs, and along the 
urinary tract, brownish casts in the renal tubes, etc. 

Doctor Bigelow refers to what appears to have been similar cases in 
one of the continental asylums, and I have met one case in some respects 
similar, which I saw with Doctor Ewing, of New York. Malignant diph- 
theria appeared in a family in West Fifty-third Street, in the middle of 
October, 1880. The patient, a boy of ten years, died, and the remaining 
two children, as soon as the nature of the malady was apparent, were sent 
from the house. Nevertheless, one of these, precisely seven days after 
the removal, was attacked by diphtheria of the hemorrhagic form, and 
died in less than one week. Blood escaped from the nostrils, fauces, 
under the skin in numerous places, causing purpuric spots and from the 
kidneys or urinary tract, causing hematuria. 

The mother, who was at this time in the sixth month of pregnancy, con- 
tinued greatly depressed by the occurrence, although she was robust, and 
her general health good. She had been in constant attendance upon her 
children. Her infant, born three months subsequently to the occurrence 
of diphtheria in her family (February 6th, 1881), was well developed, but 
it presented a similar hemorrhagic cachexia to that in the second case of 
diphtheria. Blood escaped from the vessels under the skin, causing 
blotches and prominences, and from the mucous surfaces. The bleeding- 
was especially persistent and copious from the umbilicus, so that death 
occurred in less than a week. The mother had at no time any diphtheritic 
symptoms, yet we know that the diphtheritic poison is subtle and pene- 
trative, producing its peculiar inflammation upon the uterine walls of the 
parturient woman, even when her fauces are not affected. Nevertheless 
the etiological relation of diphtheria to cases like the above is uncertain, 
and can only be determined by more numerous observations, and thorough 
examination. In the epidemic observed by Doctor Bigelow, so far as ap- 
pears from the published account, the mothers, and other inmates, were 
not affected with diphtheria, and this must give rise to grave doubt 
whether the malady affecting the infants were really diphtheritic. Diph- 
theria is infrequent after the middle period of life, and old age appears 
to possess nearly an immunity from it. 

Incubation. — It is only in exceptional instances that we are enabled to 
ascertain the incubative period of diphtheria. I was enabled to fix it very 
nearly in the following cases which occurred in my practice. A boy of 
nine years was in the same room, about one hour on Saturday, with a child 
who had fatal diphtheria. On the following Tuesday, without any other 
exposure, he sickened with a malignant form of the same disease. Mrs. E. 
assisted in nursing a fatal case of diphtheria, from November 1 1 to 13, 1874, 
after which she returned home, several blocks away. On the evening 
of the 15th she complained of sore throat, and on the following day the 
diphtheritic pseudo-membrane was observed over her tonsils. On the 19th 



250 DIPHTHERIA. 

the exudation had disappeared, and she was convalescent. On the 20th her 
sister, residing with her, and who had not been elsewhere exposed, was simi- 
larly affected, and after three or four days also convalesced. The only other 
case in the family, a boy, sickened with diphtheria on December 2. In 
the first of these cases the incubative period seems to have been from two 
to four days ; while in the last, it was apparently longer. In April, 1876, a 
little girl died of malignant diphtheria in "West Forty-first Street, New York 
city. Her sister, aged one year, remained with her from April 14 to 17, 
when she was removed to a distant part of the city, and placed in a family 
where there was no sickness, and had been no diphtheria. On the night 
of April 24, seven days after her removal, this infant was observed to be 
feverish, and on the following day, when I was called to examine her, the 
characteristic diphtheritic patch had begun to form over the left tonsil. In 
April, 1875, two sisters, aged seven and five years, resided with their parents, 
in a boarding-house, in West Twenty-second Street, New York. A play- 
mate in the same house had symptoms which were supposed to be due to 
& cold, but which were diphtheritic, when one night severe laryngitis oc- 
curred, and ended fatally the next day. The physician who had been 
summoned diagnosticated diphtheria, and the two sisters were immediately 
removed to a hotel. But seven days subsequently, diphtheria commenced 
in the older child. The younger was then removed to a distant part of 
the same hotel, but on the sixth or seventh day subsequently she also be- 
came affected with a fatal form of the disease. It is seen that the period 
of incubation in diphtheria, like that in scarlet fever, varies in different 
cases. It is from two to eight days, with perhaps an occasional case out- 
side these limits. 

Nature. — Diphtheria resembles scarlet fever in certain particulars ; in 
its incubative period, as we have seen above, in its variability of type from 
a very mild to a malignant form, in the common seat of its inflammations, 
namely, upon the fauces and nasal passages, in the profound blood-poison- 
ing and prostration in the graver cases, and in the frequent occurrence of 
nephritis as a complication or sequel. It resembles both scarlet fever and 
smallpox in the fact that it is communicable both through the atmosphere 
and by contact or inoculation. It resembles erysipelas in the variable- 
ness of its duration, and in the fact that one attack does not protect the 
system from another. In its etiology it resembles typhoid fever, for it is 
not only communicable from person to person, but it is produced by foul 
exhalations, as sewer gases. But while there are certain resemblances, it 
is distinguished from all these infectious diseases by marked peculiarities. 

Diphtheria is primary or secondary. The secondary form most fre- 
quently occurs during epidemics of the other infectious diseases, and as a 
complication of them. Those infectious maladies which are accompanied 
by inflammation of the fauces and air passages, are most liable to this 
complication if they occur in a locality where diphtheria prevails ; the 



NATURE. 251 

inflammations of the mucous surfaces accompanying them being transformed 
into the diphtheritic. In New York, scarlet fever beyond any other disease 
appears to furnish the conditions which are most favorable for the occur- 
rence of diphtheria, and if these maladies be epidemic in the same locality, 
not a few of the scarlatinous patients are affected with diphtheria in 
the latter part of the first, or in the second week, though the converse 
seldom happens, that a patient with diphtheria contracts scarlet fever. 
The other infectious diseases, which are most liable to the diphtheritic 
complication, are measles, variola, hooping-cough, and typhoid fever, 
the bronchitis of these diseases changing to a pseudo-membranous inflam- 
mation. 

It is an interesting fact that in a patient suffering from diphtheria, the 
specific inflammation is apt to occur upon such surfaces as are already the 
seat of inflammation. A catarrhal inflammation however produced is 
liable, under the influence of the virus, to become diphtheritic and pseudo- 
membranous. Thus, if I recollect correctly, four children in the New 
York Foundling Asylum have had diphtheritic conjunctivitis, occurring 
upon trachoma, and Bilbroth remarks " catarrhal conjunctivitis," which is 
so very common, may become diphtheritic" [Surg. Pathol., translated, 
page 267). All who have seen much of diphtheria are familiar with in- 
stances in which a catarrhal inflammation, as from a burn, blister, or wound, 
as from tracheotomy, becomes diphtheritic. This general fact, in regard 
to the nature of diphtheria, and its mode of manifestation, namely, that 
in one affected by diphtheria, the diphtheritic inflammations appear by 
preference upon such surfaces as are already inflamed, has an important 
practical bearing. In frequent instances during epidemics of diph- 
theria, I have known careful and experienced physicians suppose that they 
were treating catarrhal inflammation of the air passages, when suddenly 
indubitable signs of diphtheritic disease occurred, usually with a fatal 
ending. They were obliged to confess to the friends of the patients that 
they had erred in diagnosis and prognosis, and their reputation was some- 
times seriously compromised. Now may there not, at least in a certain 
proportion of such cases, be an actual change of a non-specific catarrhal or 
may be croupous to a diphtheritic inflammation, such as occurs in the 
scarlatinous angina or rubeolous laryngitis in those who contract diph- 
theria ? 

The frequent occurrence of epidemics of diphtheria during the last 
twenty-five years, and the great mortality which has attended them, have 
awakened an interest in this malady which has led to a careful study of 
its causes and nature. Till recently these inquiries were entirely clinical, 
but, during the last few years, a new line of investigation has been fol- 
lowed, namely, that of experimenting on animals, the results being ob- 
served by the microscope ; and while it has led to the confirmation of facts 
already ascertained, important discoveries have been made, and more 



252 DIPHTHERIA. 

important ones are probably in waiting. Among those who have taken 
the lead in this new field of investigation are Oertel, Buhl, and Hueter, 
of Germany. These microscopists, and several other experimenters of 
equal reputation who uphold their views, believe that they have dis- 
covered the cause of diphtheria, standing, as Oertel says, { ' on the very 
borders of the visible, ' ' with a high power of the microscope. 

This discovery is so important, not only in itself, but from the promise 
which it gives of the results of future research, and from the stimulus 
which it imparts to such inquiries, that a brief statement of the facts in 
reference to it cannot fail to be interesting at the present time, when diph- 
theria is so prevalent and fatal in this city and country. The minute 
objects which the observers alluded to have discovered in patients affected 
with diphtheria, and which, they suppose, cause the disease, are endued 
with life and motion. They belong to the class of microscopic vegetable 
parasites which have been designated bacteria. The bacteria have been 
divided by Cohn into four genera, with species ; but only two of these, it 
is thought, sustain a causal relation to diphtheria, namely, the sphero- 
bacterium or spherical bacterium, or, as Oertel designates it, the micro- 
coccus ; and secondly, though in less degree, because less numerous, though 
coexisting with the other form, and penetrating the tissues with it, the 
micro-bacterium, or rod-like bacterium. 

The microscope, in the hands of various observers, has revealed the fol- 
lowing important facts relative to diphtheria : In every tissue which is the 
seat of diphtheritic inflammation, and in every diphtheritic pseudo- 
membrane, the spherical bacteria occur in immense numbers, accompanied 
by a smaller number of the other kind. In severe cases, in which the sys- 
tem is infected, they occur also in the blood. Ordinarily, as the symptoms 
<of diphtheria become more grave, a proportionate increase in the number 
of spherical bacteria can be demonstrated by the microscope. They are 
found in the discharge from the edges of the wound produced by tracheot- 
omy, performed in the treatment of diphtheritic laryngitis, and upon these 
edges they multiply rapidly, just before a pseudo-membrane forms. If, 
upon any surface, which is the seat of ordinary catarrhal inflammation, 
other vegetable organisms, as the leptothrix buccalis, or oidium albicans, 
are present — if diphtheritic inflammation supervene, these organisms 
diminish and disappear, as if deprived of the required nutriment, and are 
succeeded by the sphero- and micro-bacteria, which increase in numbers 
as the specific inflammation extends. On the other hand, when the diph- 
theritic inflammation abates, these bacteria disappear, and other vegetable 
forms may succeed. In the very commencement of diphtheria, the grayish- 
white spots which appear upon the inflamed surface consist entirely of 
these bacteria, with epithelial cells and mucus, while fibrin and pus appear 
at a later period, as a result of inflammatory reaction. 

These facts having been ascertained, various experiments were made by 



NATURE — CAUSES. 253 

Oertel, Hueter, Von Trendelenburg, Nasseloff, Eberth, and others, in 
order to determine more fully the exact relation of the sphero- bacteria 
and micro-bacteria to diphtheria. These organisms were not found in the 
eroupous membrane, produced by the application of a powerful chemical 
agent, as ammonia, nor upon the inflamed surface underneath the mem- 
brane, ' ' although the fibrous exudation afforded a soil which varied little 
or not at all in its histological and chemical composition from that induced 
by diphtheria." (Oertel.) The mucous membrane of the air passages, 
the cornea and muscles in animals, were inoculated with diphtheritic mat- 
ter, and these two kinds of bacteria were found to increase rapidly, pene- 
trating the tissues in a short time, and infecting the system. Oertel says : 
* ' I have noticed in numerous inoculations that if various bacteria, besides 
the micrococcus, as, for instance, bacillus, spirillum, and bacterium lineola, 
were present in the matter to be inoculated, only micrococci (sphero-bac- 
teria) and the bacterium termo (in its most minute forms accompanying 
them) showed evidence of prolific growth, while all the other forms disap- 
peared altogether." Nasseloff and Eberth inoculated the cornea with 
diphtheritic matter, and found that the sphero -bacteria and micro -bacteria 
penetrated its layers, forcing them apart, and causing within a few days 
intense keratitis and the death of the animal by infection of its blood. 
" In the same way," says Oertel, " according to my experiments, the bac- 
teria spread over the mucous membrane of the trachea, beset the cellular 
elements, crowd especially into the young exudation cells, or are taken up 
by them, and gradually cause their dissolution ; they fill the blood and 
lymph-vessels, and bring about, in a mechanical way, a damming up of 
the fluids, and, as a consequence, serous exudation. As they close up the 
capillary vessels, they occasion stagnation in the blood circulation, which 
induces disturbance of nutrition in the walls of the capillaries, and even 
rupture of the same. Muscular fibres, also, which are covered and filled 
with colonies of micrococci, degenerate and slough ; in like manner, in 
severe cases, immense numbers of bacteria appear heaped up in the urinif- 
erous tubules and Malpighian corpuscles of the kidneys, and occasion 
there parenchymatous inflammation, capillary embolism of the glomeruli 
of the kidney, with ruptured vessels and formation of epithelial casts in 
the tubes. In the lymph and blood streams (compare also Hueter), in 
long-continued sickness of the animal experimented on, these bacteria 
also accumulate in masses. They induce, as exciters of decomposition and 
disorganization of organic nitrogenous bodies, septicaemia, through the 
vegetative process they undergo, and through their relation to oxygen." 

Finally, Erfurth repeatedly inoculated the cornea with a negative result, 
using for the purpose diphtheritic material from which the bacteria had 
been so far as possible separated. 

The importance of such experiments cannot be too highly estimated. In 
the opinion of those who have performed them, the conclusion is inevitable 



254 DIPHTHEEIA. 

that diphtheria is produced by bacteria, which, comiDg in contact with the 
mucous membrane, or the cuticle deprived of its epidermic covering, ad- 
here to it; and these, multiplying rapidly, burrow through the tissues, and 
entering the vessels, infect the whole system. The reason assigned why 
diphtheritic inflammation in most cases appears primarily and chiefly upon 
the faucial and nasal surfaces is, that the air, which contains the germs of 
the bacteria, constantly passes over these surfaces, and, as regards the 
fauces, the ingesta also, which may contain them. The important prac- 
tical inference from this theory is, that diphtheria is entirely local in its 
commencement, and is amenable to local measures. 

These experiments, apparently so conclusive, and the brilliant results 
claimed for them, probably produce at first in most persons engaged in 
microscopical or pathological studies, a degree of enthusiasm in the belief 
that a new era is dawning in our knowledge of the contagious and mias- 
matic diseases. And since the German microscopists and pathologists are 
close and accurate observers, we accord to their researches and opinions a 
degree of credence which we are reluctant to yield to our own scientists 
who are engaged in similar studies. 

But the causes and nature of a disease cannot, in general, be fully 
elucidated by experiments alone, such as have been detailed. They should 
be aided or supplemented by clinical observations, and of these, as regards 
diphtheria, we have had an abundance in New York during the past fif- 
teen years. Clinical observations may modify or correct the theories 
derived from the results of experiments. 

Two distinct propositions are evidently included in the bacterian theory, 
to wit : that bacteria cause diphtheria, and secondly, that this disease is at 
first local, and that afterwards it becomes constitutional or general by the 
entrance of the specific principle into the blood. Whether diphtheria be 
primarily local or primarily constitutional, or be in some at first local and 
in others at first constitutional, is of course a distinct proposition from that 
regarding the relation of bacteria to the malady ; and whatever the truth 
may be in reference to the one, does not affect the other. 

It is evident that the truth regarding the relation of bacteria to diph- 
theria is either that they are the specific principle, and therefore cause 
the disease, or that the cause is something more subtle, not yet discovered, 
which produces such deterioration of the tissues and blood that they be- 
come a nidus, in which bacteria are early and rapidly developed. My own 
belief is more and more established that the latter is the true theory ; and 
that those who believe otherwise have mistaken an effect for the cause. 
As a deteriorated condition of the buccal surface and its secretions fur- 
nishes the nidus, in which the o'idium albicans springs up, so, it seems to 
me not improbable that those minute organisms found in and upon 
the tissues in the infectious diseases, as that seen by Letzerich in pertus- 
sis, and the bacteria in diphtheria, will yet be shown to be secondary pro- 



NATURE — CAUSES. 255 

ductions, and not causative agents. From the very early appearance of 
bacteria in diphtheritic processes, -we may believe that they sustain a 
close relation to the specific principle, and that this principle is even at- 
tached to them, so that they are agents of infection, and yet withhold our 
assent from the doctrine that they are, themselves, the specific principle, 
or that it proceeds from them. 

With an experienced microscopist of New York, I have examined the 
secretions and exudations upon the fauces in various cases of pharyngitis, 
both diphtheritic and non-diphtheritic, and we ordinarily found the 
micrococcus in abundance in the inflammatory product, whether diphthe- 
ritic or non-diphtheritic, a secretion or exudation, if it had remained 
some time upon the surface of the fauces. In one case of simple pharyngitis, 
no bacteria could be discovered on the first day in the secretion which lay 
in the depressions over the tonsils, while, on the second day, numerous 
micrococci had appeared. Micrococci, then, which are not distinguish- 
able with our present means of observation from those in a diphtheritic 
exudation, may occur in great numbers in the secretions of non-specific 
inflammations, so that their presence does not afford certain indication 
of the diphtheritic disease. It is also well known that bacteria, which 
seem to be identical with those in diphtheria, are frequently found upon 
the gums and between the teeth in health. Moreover, in the intervals of 
epidemics, and in localities where diphtheria has not occurred, or has oc- 
curred rarely, the microscope discloses the existence of bacteria, which 
resemble in form and activity those found in diphtheritic products, and 
in sufficient numbers to justify the belief that they frequently pass over 
the fauces in the inspired air. How remarkable, if the bacterian theory 
be true, that fungi, which, under ordinary circumstances, are innocuous, 
should exhibit the fearful energy and destructive power which we observe 
in diphtheria ! It has however been suggested to me, that the diphthe- 
ritic bacteria may possess peculiar functions and properties, since it is very 
difficult to observe differences which may exist, and to classify organisms 
which are " just on the borders of the visible." A fact which, till it is 
satisfactorily explained, must, I think, throw doubt on the bacterian 
theory, is that the bacteria do not irritate the lungs. If, during inspira- 
tion, they are carried along the current of air, and certain of them lodge 
upon the fauces, where they produce the specific inflammation, a larger 
number must enter the lungs, where we would suppose, from the delicate 
structure of these organs and their proneness to inflammation, they would 
produce severe results ; so far from this occurring, bronchial and pulmo- 
nary catarrhs are rare at the commencement of diphtheria, and not com- 
mon at any stage of the malady. 

Since the publication of the bacterian theory, I have made microscopic 
examinations of diphtheritic pseudo-membranes, in order to observe the 
form and movements of the micrococci, and the effect upon them of the 



256 DIPHTHERIA. 

medicinal substances which I have been in the habit of applying to the 
throat in diphtheria. With a magnifying power of 500 diameters, these 
parasites are seen as dancing or oscillating points, or rather as minute cells, 
shining or opaque, according to their distance from the eye. No one can, 
I think, observe their constant motion without admitting that they may, 
when in colonies, be irritants of the tissue with which they are in contact 
in the system, diverting nutrition and disturbing the function ; and with- 
out also believing, since they are so much smaller than the blood-cor- 
puscles, that multitudes of them may enter the circulation, since, in the 
deepest portion of the pseudo-membrane, they are in immediate relation 
with the capillaries and lymphatic vessels. It is not improbable, in view 
of these facts, that the spansemia of diphtheria is partly attributable to 
these organisms in the lymph and blood, for they could hardly exist in 
these liquids in any number without interfering seriously with the nutri- 
tive process. 

We may, therefore, believe that bacteria play a certain part in pro- 
ducing the diphtheritic cachexia, while we hold that the specific prin- 
ciple has probably thus far eluded the very thorough search instituted for 
its detection. Does not also the prevalence of inflammatory throat 
affections, some of which are very mild, during an epidemic of diphtheria, 
indicate an obscure meteorological cause of the disease quite distinct 
from the bacteria ? Moreover, does not that common sequel of diphtheria, 
namely, paralysis, indicate that there is something peculiar in the diph- 
theritic virus, that it is distinct in nature and action from the bacteria 
and from septic poison ? — since those who recover from septicaemia, as it 
occurs in surgical and other cases, and in which disease bacteria are abun- 
dantly developed in the blood, have no special liability to paralysis. Another 
fact, indicating a cause distinct from the bacteria, but a cause acting pro- 
bably in the same manner as that of scarlet fever and measles, is the long 
incubative period in certain cases, as we have seen above. Fungi visible 
under the microscope, and multiplying with great rapidity, would not pro- 
bably remain a whole week in or upon the tissues without producing the 
least symptom, and then suddenly produce a dangerous disease. 

If the views expressed above be correct, it seems probable that diphtheria 
is a constitutional disease from its inception. With sufficient observation of 
cases, and careful examination of the clinical history, facts appear which, 
I think, will lead most observers to this conclusion. The importance of 
the subject will justify the following statement of some of these facts. 

1. It is a law in pathology that those diseases which have or may 
have a long incubative period — say of a week or more — are constitu- 
tional. 

2. Another fact, which indicates primary blood poisoning in diphtheria, 
is observed in certain cases, namely, the occurrence of severe constitutional 
symptoms for a longer or shorter time, perhaps for half a day, before the 



NATURE — CAUSES. 257 

appearance of the usual inflammation. Thus a girl of five years, having 
malignant diphtheria, whom I saw in consultation, was carefully exam- 
ined on the first day of her sickness by the attending physician, and, 
although he closely inspected the fauces, there was no appearance which 
indicated the nature of the malady till the subsequent day. In such 
cases, a sufficient number of which I have observed, there is apt to be 
complaint of soreness of the throat, or difficulty in swallowing, almost from 
the beginning of the general symptoms ; but the pain and tenderness seem 
to be in the deeper tissues of the neck, and the fact that redness of the 
mucous surfaco does not appear till some hours subsequently, is evidence 
that the inflammation is developed from within, and not from the irritating 
effect of the poison upon the surface. 

Again, treatment of the inflammations by the most reliable and efficient 
antiseptics and disinfectants which we possess, commenced at the earliest 
possible moment and repeated at short intervals, does not prevent the 
occurrence of indubitable symptoms of blood poisoning in cases of a severe 
type. Thus I have treated every portion of the inflamed surface, as far 
as it was accessible, every second or third hour, with carbolic acid and 
other disinfectants, almost from the very commencement of diphtheria, 
and so thoroughly that any vegetable or animal poison with which the 
remedies had come in contact would probably have been destroyed, or 
rendered inert, and yet, except in mild cases, symptoms of diphtheritic 
blood poisoning have occurred, and as early and uniformly as if less ener- 
getic local measures had been employed. While, therefore, I do not fail 
to recommend local treatment as calculated to diminish septic poisoning, 
and relieve the inflammations, I have lost confidence in it as a means of 
preventing the entrance of the diphtheritic poison into the blood. Its 
powerlessness to prevent contamination of the blood by the diphtheritic 
virus is an additional evidence that this contamination occurs indepen- 
dently of the local disease, and probably precedes it. 

3. The quick succumbing of the system in certain malignant cases is 
evidently due to diphtheritic toxaemia. We sometimes observe a fatal 
result on the second, third, or fourth day, without any dyspnoea, or suffi- 
cient laryngitis to compromise life. Cases of this kind, terminating 
fatally even in the first day, have been reported. The system is suddenly 
overpowered by the poison, struck down, as it were, by the profound 
blood change, while the inflammations are still in their incipiency. 

4. Important evidence of the constitutional nature of diphtheria is 
afforded also by the state of the kidneys. No internal organs are so often 
affected in diphtheria as the kidneys, and on account of their location and 
anatomical relation, it is evident that the poison first passes through the 
system before it reaches them. Any clinical or anatomical fact, there- 
fore, which indicates that the diphtheritic virus has reached and affected 
the kidneys, affords proof that it has penetrated the system, and poisoned 



258 DIPHTHERIA. 

the blood. Now the occurrence of albumen, with granular or hyaline 
casts, in the urine, in cases unattended by dyspnoea, affords proof of 
nephritis, caused by the action of the poison on the kidneys. 

Sir John Rose Cormack, of Paris, in a series of interesting and useful 
papers relating to diphtheria, published in the Edinburgh Medical Journal 
during 1876, states that albuminuria, and of course the nephritis on which 
it depends, sometimes begin as early as the first day. My observations 
confirm this statement, as in the following cases : 

Case I. — L. McD., aged three years, was first visited by me on Feb- 
ruary 29, 1876. I learned from the parents that she had been feverish 
during the preceding forty-eight hours, and her urine very scanty. A 
moment's examination was sufficient to show that the case was one of 
malignant diphtheria, for the fauces were already nearly covered by the 
diphtheritic pellicle, the temperature was 103J°, and the pulse 140. The 
skin was hot and dry, and there was moderate swelling under the ears, 
and a muco-purulent discharge from the nostrils. On account of the 
scantiness of the urine, the amount not exceeding f | iv-v daily, it was 
impossible to obtain sufficient for examination till the following day. It 
was then found to have a specific gravity of 1032, to contain a deposit of 
urates and hyaline and granular casts, a diminished amount of urea, and a 
large quantity of albumen. It can hardly be doubted, from the scantiness 
of the urine, and the large amount of albumen found when the urine was 
first examined, that albuminuria had been present on the first day. 

Case II. — The following was a similar case : K., aged four years, 
living in West Thirty-sixth Street, was visited by me in consultation on 
Jan. 29, 1875. Her sickness had also continued forty-eight hours ; her 
fauces were swollen, and covered with the diphtheritic pellicle, which was 
dark and offensive ; respiration guttural ; pulse 120 ; temp. 101° ; she 
had a free discharge from each nostril ; urine scanty, its specific gravity 
1030 ; it contained a small amount of albumen, with casts, and a large 
amount of urates, with no apparent diminution of the urea. Death oc- 
curred on the fourth day. 

In such severe cases, in which albumen and casts are found in the 
urine at the first visit of the physician, there can be little doubt that the 
nephritis begins nearly or quite as early as the pharyngitis, and therefore, 
since poisoning of the blood must antedate the renal disease, diphtheria is 
in these cases very early, probably from the occurrence of the first symp- 
toms, a constitutional malady. 

Again there are cases, though not frequent — three I can recall to mind 
during the last two years in my practice — in which the external manifes- 
tations of diphtheria are very mild, even insignificant, and quickly cured, 
but in which the kidneys are severely affected. The occurrence of such 
cases is best explained on the supposition that the first departure from the 
state of health is in the blood, and that the blood change gives rise to the 
inflammation of the mucous membrane externally, and of the kidneys 
internally, rather than upon the supposition that the transient and insig- 
nificant inflammation of the mucous membrane is the first event in the 



NATURE — CAUSES. 259 

series of morbid changes, and that this inflammation leads to poisoning of 
the blood, and the establishment of a much more severe and protracted 
inflammation in the kidneys. The following are histories of the cases al- 
luded to : 

The house 229 West Nineteenth Street, New York, is an old wooden 
structure, and the family, which has occupied it during the last five years, 
has been three times visited by diphtheria, the first case, that of the 
oldest child, proving fatal. In February, 1876, one of the children had 
diphtheria in a moderately severe form. He recovered, and, after my 
visits had been discontinued, his sister, aged six years, who had had scar- 
let fever when eighteen months old, became feverish, and complained of 
her throat. No rash appeared on her skin, and there was apparently no 
coryza. Inspection of the fauces by the parents revealed a small diph- 
theritic patch over each tonsil. Although diphtheria was so frightful a 
malady to this family from their past experience, the case seemed so mild 
that the parents treated it without medical attendance, by the remedies 
which had been employed for the boy. A mixture of carbolic acid, sub- 
sulphate of iron, and glycerine, was applied to the fauces every third hour, 
sufficiently often, apparently, to destroy all bacteria or other vegetable or 
animal organisms with which it might have come in contact, and within 
two or three days the inflammation of the throat seemed to the parents to 
be cured. Nevertheless, with this insignificant inflammation of the fauces, 
so quickly subdued, and with no other apparent inflammation of the mu- 
cous surfaces, there was severe internal disease going on as the result of 
the general infection. The child did not regain her former appetite ; she 
had increasing pallor, although able to play about the house ; and, finally, 
in the third week, when I was called to see her, slight oedema of the face 
and limbs was observed. Her urine, which was scanty, was found to 
contain pus and blood corpuscles, albumen, and granular casts, and nearly 
two months elapsed before, under treatment, it became normal, and her 
health was restored. 

The second case occurred in January, 1878, in West Fifty-first Street. 
A boy, aged six years, in a family in which diphtheria was occurring, had 
slight sore-throat, which abated in two or three days. It was attended by 
little or no exudation, and would not have been considered diphtheritic, 
except for the circumstances in which it occurred, and the subsequent 
history. Still, the hoy remained ill, and fretful, and four days subse- 
quently his urine was found to be very scanty and very albuminous ; and 
three days later death occurred, preceded by total suppression of urine. 
The last urine passed, which was not more than a teaspoonful, became 
nearly semi- solid by heat. There had been no scarlet fever in the family. 

The above facts indicate, in my opinion, the constitutional nature of 
diphtheria ; but within the last few years the old doctrine that diphtheria 
is local in its commencement, and is, therefore, at least in many instances, 
amenable to local treatment early applied, has been so revived and pro- 
moted by the advocates of the bacterian theory that it has had a marked 
influence upon the treatment. It does, indeed, sometimes seem as if mild 
cases, which may apparently fully recover in two or three days, with only 
local measures, could not be attended by systemic infection ; but we ob- 



DIPHTHERIA. 

serve the same mildness, though less frequently, in scarlet fever; and 
not infrequently, even in the mildest cases, the constitutional nature of 
diphtheria is shown by the return, and return more than once, of the 
pseudo-membrane after it has been fully removed by local treatment. 
The persistence of the inflammation, and of its peculiar exudative nature, 
corresponds more with the history of those phlegmasia which proceed from 
the state of the blood, than of those which are merely local. 

Diphtheria, as experiments on animals and the histories of many re- 
ported cases show,' is sometimes communicated by inoculation. Most 
frequently, however, the virus is received from an infected atmosphere. 
The anti-hygienic conditions in which it originates are well known. 
Many cases in New York are traced to sewer gases, which have escaped 
into houses through imperfect plumbing. 

When diphtheria reappeared in New York in 1858, after an absence of 
more than fifty years, some of the first and most severe cases seen by my- 
self occurred in the upper part of the city, along the old water-courses, 
where in consequence of street grading, water was stagnant and impreg- 
nated with decaying animal and vegetable matter. Though observing 
and treating diphtheria, both in its epidemic and sporadic form, during the 
last twenty-five years, I have not observed an instance in which it seemed 
to be communicated from house to house by the clothing of a third person, 
as we frequently observe in cases of scarlet fever, and sometimes of measles. 
When it spreads from house to house, or even from room to room, in the 
same house, I think that it is almost always by the visits of persons having 
diphtheritic inflammation. The area of contagiousness of diphtheria is 
therefore limited to the room in which the patient resides, or to his im- 
mediate vicinity. 

But it is well known that the sputum of a diphtheritic patient and bits 
of diphtheritic pseudo-membrane may communicate diphtheria. The ex r 
periments indeed show this, as do many observations published in the 
records of diphtheria. Therefore, caution is required that children be not 
needlessly exposed to the handkerchiefs or towels employed by a patient, 
nor to his breath, especially during the act of coughing. We may here 
repeat that in localities where diphtheria is endemic or epidemic, certain 
constitutional diseases sustain a causative relation to diphtheria. Thus 
scarlet fever furnishes the conditions in which diphtheria arises in a house 
whose sanitary state is apparently good, and when there has apparently 
been no exposure to a diphtheritic patient. In three instances I have 
known diphtheria thus originating to become dissociated from scarlet 
fever, and spread as a primary and independent malady. 

Anatomical Characters. — In the commencement of diphtheria we 
observe redness of some portion of the mucous surface. In most cases it 
is the faucial membrane which is first affected, and that part of it which 
covers the tonsils. If there be a pre-existing inflammation of one of the 



ANATOMICAL CHARACTERS. 261 

other mucous surfaces, or a portion of the cuticle denuded of its epidermis 
and inflamed, the specific inflammation is apt to appear primarily upon 
these parts, with or without its simultaneous appearance upon the faucial 
surface, a fact to which allusion has been made above. 

The inflammation varies greatly in severity and extent. In a mild 
attack it is often limited to a part of the fauces, and there are few excep- 
tions to the rule that the tonsillar portion is affected, the redness gradually 
fading away in the healthy membrane beyond. In all except the mild- 
est cases, the whole faucial surface is, in the course of a few hours, involved 
in the inflammatory process, its mucous membrane is thickened and soft- 
ened, and its follicles tumefied, and actively secreting. In severe cases 
the uvula is elongated and enlarged from watery infiltration ; the sub- 
mucous connective tissue also becomes involved to a greater or less extent, 
and swells ; and the submucous lymphatic glands, especially the tonsils, 
also swell, and are painful. The color of the inflamed surface is some- 
times a deep, bright red, almost like arterial blood ; in other cases it is a 
dusky red, which indicates a vitiated state of the blood. The dusky red 
hue is more common in secondary than in primary diphtheria : it is also 
common in the obstructive laryngitis of diphtheria, the color becoming 
more and more dusky as the obstruction increases. 

Within a day, and usually within a few hours, from the commencement 
of the inflammation, a small slightly raised patch or spot is observed, 
usually upon the tonsillar portion of the inflamed surface, of little import- 
ance, did the disease stop here, but very significant as a diagnostic sign, 
and as a forerunner of what is to happen. This patch, termed the pseudo- 
membrane, gradually becomes firmer, and at the same time thicker and 
broader from fresh exudations underneath, and it has a grayish or grayish 
white color. Sometimes different points or patches are observed, which 
extend and coalesce so that the fauces are almost entirely concealed from 
view. The pseudo-membrane is closely attached to the mucous surface, 
which it penetrates, becoming firm, and not easily detached. Attempts 
to separate it often lacerate the engorged capillaries, producing a free flow 
of blood. It does not ordinarily attain a greater thickness than one- 
eighth to one -sixth of an inch. I have seen it, however, not far from 
one -third of an inch thick. By the microscope we observe numerous 
micrococci with a small number of rod-like bacteria in the meshes of the 
exudation. They can be traced through the subepithelial tissues, being 
adherent to and even incorporated in pus-cells, and entering into and 
blocking up the minute lymphatics and bloodvessels. 

The same pseudo-membrane is often firmer in one part than another, 
the outer and central portions being more compact and tough for a time 
than that underneath, which is more recent, and in which there is less fibril- 
lation. After a few days, however, decomposition commences, and then 
that which was first formed becomes softer than the more recent produc- 



262 DIPHTHERIA. 

tion. When this occurs, the color of the exudation changes from a whit- 
ish or a grayish white to a dirty brown, and its exposed surface is uneven 
and jagged from the partial separation of shreds and fibres. 

The escape of the liquor sanguinis from the engorged vessels diminishes 
somewhat the turgescence of the inflamed tissue. If this be considerable, 
the pseudo-membrane often sinks to the level of the surrounding sur- 
face, producing an appearance very much like that of an ulcer, or even 
of gangrene. Though there is no loss of substance in this stage of the 
pseudo-membrane, it does, however, often occur, being produced by the 
presence and contraction of the fibrin with which the mucous membrane 
is infiltrated. Sometimes the pseu do- membrane has a reddish tinge. 
This is due to rupture of the capillaries, and the escape of the blood-cor- 
puscles. It occurs in those cases in which the inflammation is intense, 
and the capillaries are greatly engorged. Sometimes the lower part of 
the exudation is blood-stained, while the exposed surface has the usual 
grayish white hue. For a very interesting and instructive description of 
the anatomical characters of the diphtheritic pseudo-membrane, the reader 
is referred to the treatise of Prof. Rindfleisch, of Bonn, relating to patho- 
logical histology. His description is as follows : 

1 ' Genuine diphtheritis has no claim to be regarded as a specific process 
in the same measure as croup. That which microscopically characterizes 
it, and has become the occasion of placing it as a membranous inflamma- 
tion is the formation of a whitish-gray, compact, felted membrane, which 
is elevated, perhaps, to the height of one-half line along the level of the 
mucous membrane, but penetrates just as deep into the substance of the 
mucous membrane, and is most intimately connected with the latter. This 
membrane is nothing that is superimposed, nothing secreted, but the mucosa 
itself, as far as it has been partly tumefied, partly rendered anaemic, 
even by the excessive infiltration with cells. This condition has not im- v 
properly been compared with a mortification by a chemical agent, with a 
corrosion, and the diphtheritic membrane has been designated as diph- 
theritic scab ; in fact the diphtheritic membrane is a caput mortuum, it 
can undergo no other changes than those of putrefaction, of decomposition ; 
and the question only is, how it is loosened and removed from the inti- 
mate organic connection in which it stands with the mucous membrane. 
A sharply defined boundary line separates, as we can convince ourselves 
with the naked eye, the living from the dead ; but numerous connective- 
tissue fibres, bloodvessels, nerves, and elastic fibres, pass over from the 
the living into the dead ; they must all have separated ere the loosening 
can proceed. The means which are placed at the command of the 
organism are inflammation and suppuration. We call this inflammation 
' reactive, ' and unite with it the idea as though this were an answer to the 
irritation, which the diphtheritic scab exerts upon the surrounding mucous 
membrane ; yet a portion of the hyperaemia also may be explained accord- 



ANATOMICAL CHARACTERS. 263 

ing to static principles as collateral fluxion. The pus collects between the 
scab and the healthy parts and always, accordingly as the fibrous bridges 
mentioned melt down and tear, the separation begins now at the edges, 
then at the centre. After it is completed an ulcer remains behind which 
is disposed to rapid cicatrization ; not unfrequently, however, the process 
repeats itself again at the same place ; we have a new scab, and with it 
anew the necessity of a purulent separation, after whose termination a 
very considerable loss of substance remains. The cicatrices finally result- 
ing distinguish themselves by their capacity of vigorous retraction, so that 
the danger of subsequent contraction of mucous membrane canals, espe- 
cially of the large intestine after dysentery, threatens so much the more, 
the more diffused the ulceration was." [Text-book of Pathological His- 
tology, translated, page 354.) 

Two of the microscopists of New York who, for years, have been en- 
gaged in microscopical and pathological studies, kindly consented to ex- 
amine for me the anatomical characters in the following cases. The 
examinations in the first, second, and fourth cases were by Dr. Sather- 
thwaite ; in the third by Dr. Heitzman, formerly clinical assistant to Prof. 
Rokitansky, in Vienna. The specimens were placed in a solution of 
bichromate of potassium immediately after their removal from the bodies : 

Case I. — H , aged four years, and two brothers S., who lived di- 
rectly opposite in the same street in New York, were daily playmates. 

On January 27, 1876, H became feverish and complained of sore 

throat, and four days subsequently died of malignant diphtheria. This 
case was carefully examined by me in consultation, and minute records of 
it preserved. Before it terminated, the two brothers S. became affected 
with diphtheritic laryngitis. The younger brother, aged three years, was 
for a time in a very critical state from the dyspnoea, but recovered in about 
one week. The older brother, aged six years, died, having the following 
history : On January 29, two days after the commencement of diphtheria 

in his playmate, H , he vomited and became feverish, and his voice 

hoarse. These symptoms continuing, I was asked to visit him on Febru- 
ary 2. His respiration at this time was harsh, and audible in the adjoin- 
ing room, and the cough croupy ; pulse 96 ; temperature in axilla 100° ; 
he takes considerable nutriment, and sits quietly, or walks about the room ; 
fauces red, and slightly swollen, but without any diphtheritic exudation 
upon their surface ; has slight glandular swelling underneath the ears ; the 
urine contains no albumen, and the nitric-acid test shows no excess of 
urea. The constant inhalation of the spray of lime-water is recommended, 
with the use of tonics. Feb. 4. Pulse 96, temperature 99° ; breathes with 
much difficulty at times, but there is still no pseudo-membrane upon the 
fauces ; has expectorated since the last record two thick pieces of pseudo- 
membrane, each about one inch in length, apparently from the larynx ; 
specific gravity of urine 1022 ; it contains a deposit of urates, but no albu- 
men ; urea apparently somewhat in excess of the normal quantity. Feb. 
5. Pulse 92 ; temperature 10 If ° ; has a small diphtheritic patch, not more 
than three lines in diameter, over the left tonsil. Feb. 6. The pellicle 
upon the tonsils has disappeared ; the urine for the first time albuminous, 



264 DIPHTHERIA. 

thirty-six hours before death ; its specific gravity 1024 : temperature 103° ; 
dyspnoea great ; pulse about 120. Death occurred on Feb. 7. 

Sectio Cadaver is, nineteen hours after death. — Body spare, but not 
emaciated ; rigor mortis present ; has post-mortem extravasation of blood 
along the back, and a thin blood-stained fluid escapes from the mouth ; two 
or three drachms of transparent liquid in the pericardial sac ; a large yellow- 
ish-white clot fills the right ventricle, and is prolonged into the pulmo- 
nary artery ; the right auricle also contains a large clot, soft and dark in its 
centre, but firmer and of a whiter color externally ; left ventricle contains 
a few soft dark clots, with a little fluid blood ; left auricle partly filled with 
blood of a tarn- appearance ; tonsils not enlarged, but soft, and a yellowish 
diffluent secretion lies in the depressions on their surface ; subcutaneous 
glands of the neck slightly enlarged, one being somewhat larger than a 
filbert ; under surface of epiglottis, and entire surface of larvnx, covered 
by a firmly adherent pseudo -membrane which entirely conceals from view 
the vocal cords and sinuses of Morgagni ; the pseudo-membrane is 
continued over the surface of the trachea, being less adherent than in the 
larynx, and, near the bifurcation, it floats freely ; it does not extend into 
the bronchus or bronchial tubes of the left lung, and this lung is normal. 
In the right lung the pseudo-membrane extends as far as the bronchial 
tubes of the third order ; the upper lobe of the right lung is in the second 
stage of pneumonia, its cut surface being rough and granular, and liquid 
escaping from it on pressure ; the right, middle, and lower lobes are con- 
gested, and in the lower lobe is a single hepatized nodule ; those portions 
of the bronchial tubes which are not covered by the false membrane ex- 
hibit the appearance of catarrhal bronchitis. The liver is large, and 
not fatty; spleen small, moderately firm, and contracted (this is noteworthy, 
as the spleen has been found large and soft in diphtheria) ; kidneys con- 
gested and swollen, and a stellate appearance of the vessels under their 
capsules ; surface of both small and large intestines congested. 

Microscopic Examination. — Red corpuscles of the blood well-preserved, 
some of them round, others crenated, and all granular ; large masses of 
transparent material, containing red corpuscles, floated in the blood. The 
rod and chain forms of bacteria were observed in the blood, but not in 
greater number than are often seen in other blood the same number of 
hoars after death. (A few grains of chloral had been added to this spec- 
imen of blood immediately after its removal.) Substance of heart appar- 
ently normal, showing no fatty degeneration, nor infiltration ; no bacteria 
can be recognized in the substance of the heart. Kidneys : Right kidney 
examined ; Malpighian bodies congested, and extravasations of blood 
throughout this organ ; tubal epithelium granular ; increase of connective 
tissue in points near periphery of kidney, showing insterstitial nephritis, 
but no increase observed in this tissue in other parts of the organ ; no 
bacteria that could be certainly recognized as such in the kidney. Spleen : 
Multitudes of granules in scrapings from the cut surface of this organ, 
many of them so small as to be with difficulty recognized with a magnify- 
ing power of over 600 diameters ; some of them gave the appearance of 
the usual forms of bacteria. 

Larynx : Thickness of false membrane which covered the entire surface 
of this organ varied from yj^ to -^V of an inch ; thickness of mucous mem- 
brane about J^r of an inch ; epithelial border of mucous membrane could 
be traced inwards -^-q to y^- of an inch, where it became indistinct, merg- 
ing into the other tissues, which were more or less infiltrated with embrvonic 



ANATOMICAL CHARACTERS. 265 

cells and blood. The false membrane consisted of a network of a homo- 
geneous material, most of the meshes being empty, but those nearest the 
epithelial layer containing more or fewer epithelial cells. The boundary 
line between the false membrane and mucous surface could not be dis- 
tinguished by the microscope in many of the sections, the network of the 
pseudo-membrane extending into the mucous membrane. But in other 
places the line of separation could be distinguished, and here and there 
the pseudo-membrane and mucous surface were separated by collections of 
embryonic cells. The lymph follicles and racemose glands were appar- 
ently normal ; mucous surface infiltrated with granular matter and red 
blood corpuscles ; cylindrical epithelial cells, some of them with cilia, were 
distinctly visible both along the free border, and in the under surface of 
the pseudo-membrane. Trachea : The false membrane measures from 
about yi-Q to -Jy- of an inch in thickness ; the mucous membrane -^ of an 
inch, and its epithelial layer j |-g- of an inch ; the epithelial cells are much 
more distinctly visible than in the larynx, and the line of separation of the 
adventitious layer and the mucous surface is everywhere distinctly seen 
under the microscope ; the false membrane has the same general appear- 
ance as in the larynx ; but the mucous membrane is in a better preserved 
state than that of the larynx ; it is nevertheless infiltrated with granular 
matter, plastic matter, and red blood-corpuscles ; lymph follicles and race- 
mose glands apparently normal ; in the trachea, as in the larynx, a large 
number of embryonic or lymphoid cells — most of them no doubt becoming 
pus cells — lay between the false membrane and the mucous surface. 

Case II. — A second case, having the following history, occurred in the 
New York Foundling Asylum in New York. George, aged two years and 
seven months, was under treatment for a second attack of measles, the 
eruption appearing on March 23, 1876. On March 24, the pulse was 136 
and temperature 104£°. The fauces presented a deep-red appearance in- 
dicating severe pharyngitis, but without any membranous exudation. 
March 25. Pulse 140 ; temperature 103^° ; the rubeolar eruption is very 
thick over the entire surface. The Sister who has charge of the ward, 
noticing unusual off ensiveness of the breath, has inspected the fauces and 
found on them the diphtheritic pellicle. March 26. Cough becoming 
croupy, and voice hoarse ; pulse 152 ; temperature 105J . From this 
date the dyspnoea progressively increased, and death occurred on March 30. 

Sectio Cadaver is. — A considerable part of the interior of the larynx is 
coated with the diphtheritic pseudo-membrane, which is firmly attached to 
the mucous surface ; it extends without interruption over the larynx, and 
perhaps over one-third to one-half of the tracheal surface. It is not attach- 
ed to this surface, but hangs over it like a curtain, suspended from its 
attachment in the larynx. Farther down in the air passages there is the 
usual catarrhal inflammation of the mucous surface. 

Microscopic Examination. — Larynx: The false membrane is found to 
consist of a network, apparently fibrinous ; in places, in the larynx, it is 
raised from the mucous membrane by an accumulation of embryonic or 
lymphoid cells underneath ; in other places it is adherent to the mucous 
membrane, but with a line of attachment which can be distinctly made out 
with the microscope ; while in other places still the network extends down 
into the mucous membrane, and no distinct line of separation can be seen. 
In the upper or exposed portion of the false membrane, no embryonic or 
lymphoid corpuscles are observed, but they are abundant in the deeper 
portion, and they infiltrate the whole mucous membrane extensively ; upon 



266 DIPHTHERIA. 

the mucous surface, wherever the pseudo-membrane is detached, these cor- 
puscles are abundant ; in parts of the false membrane they fill so com- 
pletely the interstices of the network that epithelial cells can scarcely be 
distinguished within them ; in places, in the sections examined, the epithe- 
lium seemed to be wholly replaced by granular matter ; in general, the 
border line between the diphtheritic membrane and the mucous surface is 
marked by a somewhat denser exudation of the albuminate — a fibrinous 
appearing material — than is seen in the false membrane generally ; the 
bloodvessels in the mucous membrane of the larynx are numerous, and dis- 
tended with blood. Trachea : The epithelium, consisting of from two to 
three layers, is seen to be intact wherever it is observed ; the surface of 
the epithelium is covered with minute markings, probably the cilia in con- 
traction ; the pseudo-membrane is not seen to be reticulated as in the 
larynx, perhaps from the contractions which had occurred in it ; it ap- 
peared granular and fibrous, and contained but few corpuscles. Lungs : A 
portion of one lung was found hepatized, and the alveoli of this portion 
contained pus cells, epithelial cells, blood, and a fibrinous appearing mate- 
rial (croupous pneumonia) . Kidneys : The changes observed in these 
organs were those of tubal nephritis ; the tubes were highly granular, both 
in the pyramids and cortex ; no increase in the interstitial connective tissue 
was noticed ; in places the tubes were not granular. The muscular tissue 
of the heart seemed normal. 

Case III. — J , aged four years, an inmate of the New York Found- 
ling Asylum, began to have a sore-throat on March 4, 1876. The fauces 
were red and somewhat swollen, but without any membranous exudation, 
and the diphtheritic nature of the disease was not at first suspected. My at- 
tention was first called to this case on March 1 1 , on account of almost total 
suppression of urine. The fauces were still injected, and somewhat swollen 
from catarrhal inflammation ; there was a copious muco-purulent discharge 
fom the nostrils ; pulse 148. March 13. Pulse 144 ; temperature 101J° ; 
urine still nearly suppressed, though one drachm of infusion of digitalis is 
administered every fourth hour, and bromide of potassium, four grains, 
every second or third hour, for the restlessness. Dr. Reid, in using the 
catheter, observed a diphtheritic patch on the vulva ; there is moderate 
tumefaction under the ears ; the patient vomits often during the last days ; 
she has livid spots, from extravasation, under the skin ; and vision is much 
impaired, if not lost ; it is impossible to obtain any urine for examination. 
Death occurred without convulsions on March 15. 

Microscopic Examination of the Kidneys. — The tubuli contorti of the 
first and second order of the cortical substance of the kidney almost all 
enlarged ; their epithelium swollen in many places to such a degree that 
no calibre of the tubules can be seen ; the epithelium richly provided with 
coarse granules, the enlarged living matter ; the original cement substance 
missing ; instead of this, new transparent lines formed within the proto- 
plasm, indicating the earliest stage of catarrhal inflammation, with parti- 
tion and new formation of epithelial elements ; the same changes, though 
in a less marked degree, observable in the epithelium of the straight ducts 
of the pyramidal substance, while the flat epithelial bodies of the narrow 
ducts apppear almost unchanged. The connective tissue between the ducts 
and the enlarged glomeruli is somewhat increased in size, and it contains 
newly-formed nuclei in moderate number, with enlarged bloodvessels, some 
of which are much distended with blood-corpuscles ; no fatty degenera- 
tion in kidneys. In a few places, accumulations of dark granules occur 



ANATOMICAL CHARACTERS. 267 

within the ducts and their epithelium. These granules, not being 
united with each other by threads, nor staining with carmine, are consid- 
ered to be micrococci, such as occur in any decomposing animal tissue. 
Whether they were present during the life of the patient, or were due to 
early cadaveric putrefaction (which is common after death from diph- 
theria), is uncertain. But since I have seen micrococci and bacteria in the 
fresh urine of children suffering from diphtheria, I would not deny the 
possibility of the occurrence of micrococci in the uriniferous tubules during 
life ; nay, even, they may produce the inflammatory process in a way 
still unknown to us. In the case under consideration no trace of casts was 
found within the tubules, so that the inflammatory process doubtless was 
not a croupous one, but a relatively slight process, termed catarrhal or in- 
terstitial nephritis. 

Case IV. — M., aged four years, inmate of the New York Foundling 
Asylum, New York, began to be sick May 6, 1876 ; was languid and fever- 
ish, temperature 104°, had redness of fauces and an exudation over each 
tonsil, no coryza; evening temperature 103°. May 7. Pulse 120 ; tem- 
perature 100°. May 8. Pulse and temperature as yesterday ; urine scanty; 
no albuminuria, and no discharge from nostrils: the membrane extends from 
the sides of the throat to the roof of the mouth ; specific gravity of urine 
1021, urine contains no albumen, no excess of urea, and no deposit of 
urates. May 10. Pulse 140 ; has considerable oedema of fauces, and 
breathing guttural in sleep ; vomited once since yesterday ; the urine con- 
tains for the first time a moderate amount of albumen, with hyaline casts ; 
specific gravity 1018, acid ; no urea deposited on adding nitric acid ; that 
alarming symptom in diphtheria, epistaxis, has occurred to-day. The 
records which were written daily till death, which occurred on the 14th, 
show a gradual increase of albumen with hyaline casts in the urine, in- 
creasing scantiness of urine, so that on the 13th not more than half an 
ounce was passed in twelve hours ; temperature not rising abeve 100J°, 
nor pulse above 108 ; poor appetite, occasional vomiting, and epistaxis. 
Death occurred from feebleness and blood poisoning, notwithstanding that, 
from the first day, three grains of salicylic acid were given the first hour, 
two grains of quinine the second hour, and tincture of iron and chlorate 
of potassium the third hour, these doses having been continued night and 
day in alternation; with the application of carbolic acid and subsulphate of 
iron to the fauces, three times daily ; with nutritious diet, and the mode- 
rate use of stimulants. There were no symptoms referable to the larynx, 
unless a slight cough. 

Sectio Cadaveris. — Mucous membrane of larynx, trachea, and bronchial 
tubes intensely and uniformly injected, but without any membranous exu- 
dation ; lungs fully inflated, as if from commencing vesicular emphysema, 
and pale in front ; numerous extravasations of blood in the substance of 
the lungs and other organs ; the haemorrhages in and under the mucous 
membrane of stomach so abundant that the gastric surface presented a 
mottled appearance like the skin in measles. 

Microscopic Examination. — The mucous membrane of the larynx and 
trachea was hyperaemic, but was otherwise apparently normal ; muscular 
tissue of heart normal ; spleen soft, but not appreciably enlarged. The 
scrapings of the cut surface of this organ contained red blood-corpuscles ; 
bodies from two to five times the size of the blood-corpuscles, holding in 
their interior oil-drops and fine granules, and having a yellowish-red color ; 
granular lymphoid corpuscles, and granular debris. The walls of the 



268 DIPHTHERIA. 

stomach were congested, but without any noticeable exudation upon the 
surface ; the extravasations of blood, described above, were found to be 
chiefly in the submucous tissue. In some places the gastric tubes were 
bare, but in other places covered with amorphous matter ; but whether the 
covering substance was altered epithelium or diphtheritic exudation was 
not determined. The epithelium covering the more exposed portions of 
the tubes was in many places not distinct, while that covering the deeper 
portions of the tubes was clearly defined ; at the pylorus, upon the valve, 
the mucous membrane was deficient ; those portions of the true peptic 
glands lying below the tubes were normal. The mucous membrane in the 
lower part of the ileum was congested. Peyer's patches, and the solitary 
glands, both in the ileum and large intestines, were prominent, and sur- 
rounded by halos or rings of inflammation. Both the cortical and pyra- 
midal tubes of the kidneys contained granular epithelium. 

Briefly stated, therefore, the exudation of diphtheria is found to consist 
of fibrin forming a delicate interlacing network, epithelial cells more or less 
altered by the inflammatory process, leucocytes, nuclei, mucus, and amor- 
phous matter. Upon the faucial, buccal, laryngeal, and perhaps also nasal 
surfaces, the pseudo-membrane penetrates the entire mucous membrane, 
so that no line of demarcation between them can be seen with the micro- 
scope. Below the larynx upon the surface of the trachea and bronchial 
tubes, a distinct line of demarcation exists, as in the croupous exudation, 
so that the tracheal and bronchial pseudo-membrane can be readily de- 
tached, without impairing the integrity of the underlying mucous surface. 

The inflamed mucous membrane is not only hypersernic and infiltrated 
with serum, but it contains numerous round white corpuscles (leucocytes) 
which may result in part from proliferation of connective tissue corpuscles, 
but are believed by most pathologists, since Cohnheim's well-known dis- 
covery, to be in great part wandering white corpuscles of the blood, which 
have escaped through the walls of the bloodvessels along with the fibrin. 
In the commencement of the diphtheritic inflammation, before the pseudo- 
membrane forms, we often observe a grayish tinge of the mucous surface, 
which is due to the crowding of these cellular elements underneath and in 
the mucous membrane, for these newly-formed cells can be traced into the 
submucous connective tissue. Even where the inflammation remains 
catarrhal, as it does over certain areas in all cases of diphtheria, this in- 
filtration of the mucous and submucous tissues with cells is common. 

No certain and invariable chemical or microscopical difference has yet 
been established between the pseudo-membrane of croup as described in 
the appropriate chapter and that of diphtheria. The difference universally 
recognized is this, that while the croupous membrane in all situations lies 
upon the mucous membrane, and does not penetrate it, that of diphtheria, 
in the localities where it most commonly forms, namely upon the buccal, 
faucial, and laryngeal surfaces, penetrates and becomes blended with the 
mucous membrane, so that it cannot be detached by force without the risk 
of injuring this membrane, and lacerating its vessels ; moreover, by its 



ANATOMICAL CHARACTERS. 269 

presence in the mucous layer, it is apt to obstruct circulation in it and 
cause ulceration, even in the submucous tissue. 

During the height of the inflammation, it is astonishing often to see 
with what rapidity the pseudo-membrane returns, when removed by force. 
A few hours suffice to restore it as firm and extensive as before the inter- 
ference. In favorable cases this adventitious layer is detached in a few 
days, and is either expectorated or swallowed with the ingesta. Its sepa- 
ration is promoted by the secretions underneath, especially by pus, which 
is formed in abundance between it and the surface on which, and in which 
it lies. In most cases it does not separate in mass, but disappears, by pro- 
gressive liquefaction, a little less remaining at each visit till all is detached. 

Such are the appearances, character, and history of the pseudo-membrane 
in this malady. Although its common seat is upon the fauces, and in mild 
cases it occurs only upon the fauces, nevertheless all the mucous surfaces 
are liable to be attacked by the inflammation, in consequence of infection 
of the blood, and therefore in severe cases, and even in cases of moderate 
severity, we often find the product elsewhere, as well as upon the fauces, 
and in localities where from its mechanical effect it greatly increases the 
danger and even compromises life. The mucous membrane of the nostrils, 
mouth, larynx, trachea, oesophagus, stomach, intestines, conjunctiva, vagi- 
na, and even the delicate lining of the middle ear, are at times the seat of 
diphtheritic inflammation, with the characteristic product. If the exuda- 
tion occur in the larynx or air-passages below the larynx, we have diph- 
theric croup, more dangerous even than true croup ; if upon a surface 
concerned in the digestive process, this function is more or less interfered 
with. In a case which occurred in the Nursery and Child's Hospital of 
New York, the surface of the stomach was almost completely lined with 
the diphtheritic formation, so that the function of this organ was ap- 
parently nearly or quite abolished. The occurrence of the pseudo- 
membrane in the nares is common, and is attended by the discharge of thin 
mucus and pus, but though inconvenient to the patient, its mechanical 
effect is not dangerous, except in the nursing infant, in whom it interferes, 
more or less, with lactation. The thin irritating discharge produces exco- 
riation around the nostrils, and upon the upper lip. I have met only one 
case of diphtheritic inflammation of the intestines, in which the diagnosis 
was certain. A physician, in whose family severe diphtheria had just 
occurred, took what was believed to be typhoid fever. After a long sick- 
ness he expelled, per rectum, about one foot of diphtheritic pseudo- mem- 
brane in a cylindrical form, evidently produced upon the intestinal walls. 
In the subsequent months the patient suffered from constipation, and 
severe abdominal pains, apparently due to contraction in the healing of a 
large diphtheritic intestinal ulcer. Death finally occurred from this state 
of the intestines. The formation of the diphtheritic pellicle upon the 
vulva and vaginal walls is occasionally observed, as in one of the cases 



270 DIPHTHERIA. 

related above. Its occurrence upon the uterine surface is very rare, ex- 
cept in the parturient woman, in whom it is said to occur by preference 
upon that part from which the placenta has been detached. I have met 
only one case of uterine diphtheritic inflammatiou, the disease having been 
contracted during or immediately after parturition, and ending fatally with 
all the symptoms of acute metritis within the first week. 

In mild cases of diphtheria, in which the pseudo-membrane is small, 
and quite superficial, penetrating but little the mucous membrane, in which 
it is imbedded, there is little danger of septic poisoning. But in grave 
cases, in which the diphtheritic pellicle is extensive, and deeply embedded, 
so that the lymphatic and blood vessels are in immediate relation with its 
under surface, the conditions in which septicaemia occurs, are present, as 
soon as decomposition begins. Therefore septicaemia is properly regarded 
as a not infrequent and dangerous accident in severe diphtheria, but it is 
obviously very difficult to distinguish septic from diphtheritic blood poi- 
soning, from the symptoms. Septicaemia is most apt to occur in those 
cases in which pseudo-membrane has become dark gray, and friable, 
from decomposition, producing an ichorous discharge and offensive breath 
and in cases in which blood escapes from the capillaries underneath. 

Absorption of the poisonous substance produces inflammation of the 
lymphatic vessels, along which it passes, and of the lymphatic glands, 
which these vessels enter. The adenitis also gives rise to inflammation of 
the periglandular connective tissue, so that the neck is thickened, hard, 
and tender. If we examine a gland which is swollen and inflamed by the 
toxic absorption, we will find that its bloodvessels are congested, and its 
cells have undergone hyperplasia. The periglandular connective tissue is 
©edematous, and sometimes infiltrated with lymphoid cell-nuclei and pus- 
corpuscles. Capillary haemorrhages are also common in the connective 
tissue, and micrococci are found in the lymphatic vessels, lymphatic glands, 
and in the connective tissue. 

Bronchitis also occurs in certain cases. It is usually simple or catarrhal, 
but in some patients it is pseudo-membranous in some of the tubes, espe- 
cially in the larger, or in those which are located in the posterior part of 
the chest, while in the other tubes it is catarrhal. 

If death occur from obstruction in the air-passages, the lungs will be 
found much reduced in size, the anterior superior portions being pale from 
lack of blood, and perhaps emphysematous, while the posterior and in- 
ferior portions have a dark-red color, many of the lobules being collapsed, 
and others not only collapsed or semi-collapsed, but in the commencement of 
pneumonia. This difference in the state of different parts of the lungs, in 
those who have died of suffocation in consequence of the presence of the 
false membrane in the air-passages, receives partial explanation from the 
seat of the exudation in the bronchial tubes, for in those who perish from 
this cause the exudation is found chiefly in such tubes as pass to the pos- 



ANATOMICAL CHAKACTEKS. 271 

terior and inferior parts of the organ, while such as pass to the superior 
and anterior lobules remain free from it. In some instances, in parts of 
the lungs the pseudo-membrane can be traced along the minute bronchial 
tubes into the alveoli, where it forms a network — containing in its inter- 
stices pus, and sometimes blood-corpuscles, and more or fewer micro- 
cocci. Pneumonia is also a common complication, resulting from 
downward extension of the bronchitis, or occurring independently of the 
bronchitis. 

The muscular fibres of the heart in diphtheria, as in all acute infectious 
diseases, are liable to granulo-fatty degeneration, so that they become 
softer, have a color which French writers liken to that of new leather or 
coffee and milk. This degeneration has been observed only in a certain 
proportion of the more malignant cases, and is far from being uniform. 
Any portion of the heart may undergo this change. It may occur in the 
columnse carneae, or in the walls of the organ. White fibrinous clots 
are sometimes seen in the cavities of the heart after death from diph- 
theria, and it is the accepted belief, in consequence of the symptoms 
and mode of death, that in a certain proportion of such cases the clots 
are ante-mortem, having formed some hours before the agony. It is well 
known that similar clots, thought to be ante-mortem, are not infrequent 
in fatal scarlet fever. 

The blood in cases of a severe type is usually darker than in health, and 
the clots soft. After death from diphtheritic laryngitis, it is also dark 
from excess of carbonic acid in it. The chemical changes which the blood 
undergoes in diphtheria are little known. MM. Andral and Gavarret 
found a notable diminution of fibrin in grave infectious diseases, as 
typhoid fever, puerperal fever, etc., and it is not improbable that the same 
is true of diphtheritic blood, although the exudation of fibrin is so abundant. 
M. Bouchut and others have found a marked excess of the white corpus- 
cles in the blood in a considerable proportion of diphtheritic patients, so 
that, instead of three or four in the field of the microscope, as many as 
sixty have been counted. M. Sanne writes of diphtheria "It is neces- 
sary to recognize in the dark-brown blood an abnormal accumulation of 
the debris of the red corpuscles, debris of little abundance in the normal 
state, augmented considerably under the noxious influence of the diphthe- 
ritic poison, which has rapidly produced destruction of a great number of 
globules" (Traite de la Diphtherie, page 107, Paris, 1877). Small extrav- 
asations of blood in various organs are among the most constant lesions. 
They have been most frequently observed in the brain and its meninges, 
the lungs, spleen, and kidneys. In one of the cases which I examined 
after death in the New York Infant Asylum, as I have stated above, the 
extravasations in and under the gastric mucous membrane produced a 
mottling as great as that of the skin in measles. 

No notable changes have thus far been observed in the nervous centres,. 



272 DIPHTHERIA. 

with the exception of the apoplectic foci, and softening of adjacent brain 
substance, and the congestion present when death has resulted from diph- 
theritic croup. But certain degenerative changes have been discovered in 
the peripheral nerves, as well as in the muscles in parts affected with diph- 
theritic paralysis. Thus, in nerves from a paralyzed palate, certain nerve 
tubes have been observed nearly or quite destitute of medullary matter, 
though this is not common, but many tubes are found to contain fatty 
granules, the result of retrogressive metamorphosis (MM. Charcot and 
Vulpian). 

The liver does not appear to be seriously engaged or its function com- 
promised. In most acute infectious diseases which are fatal in consequence 
of blood poisoning, the spleen is apt to become softened and somewhat 
enlarged, but this does not always occur in diphtheria. It will be recol- 
lected from the cases related above that the spleen may not be perceptibly 
enlarged or softened. 

The kidneys of all the internal organs are most frequently affected, as 
is shown by the common occurrence of albuminuria. Parenchymatous 
nephritis, with the characteristic hyperemia and swelling, is the usual 
form of kidney disease which complicates diphtheria. In the albuminous 
urine are found hyaline and granular casts. This inflammation may begin 
early in grave cases, even as soon as the first or second day, but its com- 
mencement is ordinarily not till toward the close of the first week or in 
the second. It occurs in the majority of those severe cases which prove 
fatal from blood poisoning. Interstitial nephritis also complicates certain 
cases, as one of those related above, giving rise to an increase in the 
connective tissue. 

Symptoms. —In general, in the commencement of an epidemic, diph- 
theria is more severe and fatal than when the epidemic influence is abat- 
ing. The prominent symptoms, such as arrest the attention of the friends, 
are often disproportionate to the gravity of the attack. Striking cases 
illustrative of this have occurred in my practice, the friends not supposing 
that there was any serious ailment, and not seeking medical advice till the 
fatal termination had nearly arrived. The initial symptoms are sometimes 
mild, such as chilliness or rigors, often slight, and succeeded by moderate 
febrile reaction, languor, and perhaps more or less headache, pain in the 
limbs or back, and impaired appetite. Still the patient may continue to 
walk about as if affected with slight and temporary ailment. Such cases 
in New York city frequently attend the schools, and do immense harm in 
propagating the disease. The symptoms in these mild cases are often like 
those from a cold, for which light attacks of diphtheria are apt to be mis- 
taken by the friends. With some, in mild as well as severe diphtheria, one 
of the first symptoms is slight tenderness or a sensation of fulness in the 
fauces. A distinguished clergyman of the Pacific coast, who fell a victim 
to this disease, dreamed, a few nights before he complained of illness, that 



SYMPTOMS. 273 

his throat was cut. Doubtless the diphtheritic inflammation had already 
commenced, so that what seemed a forewarning had a natural explanation. 
So insidious was the commencement in this case that the disease had ad- 
vanced beyond all hope of relief when medical advice was first sought. But 
in most cases, other than those of a very mild type, the commencement is 
more severe, being attended by a temperature of 102° or 103°, or even 
104°, with corresponding heat of surface, thirst, languor, loss or 
impairment of appetite, tenderness of throat, etc. Delirium as well as 
eclampsia may occur, but both are rare. The febrile reaction ordinarily 
abates considerably by the close of the second or on the third day, as I 
have noticed in many observations. 

The symptoms of invasion have less prognostic value in diphtheria than 
in most other infectious maladies. We meet cases with a severe begin- 
ning, attended by delirium, which terminate in apparently complete 
restoration to health in less than a week, the presence of the characteristic 
pellicle upon the fauces and the occurrence of diphtheria in other members 
of the family rendering the diagnosis certain. On the other hand, a mild 
commencement sometimes ushers in a fatal form of the disease. This is 
notably true of those cases in which laryngitis supervenes, as it not infre- 
quently does in cases which begin very mildly. 

The fever which ushers in diphtheria abates, as stated above, after the 
second or third day, and subsequently, in grave as well as in benign cases, 
there may be but little or even no elevation of temperature. The diphthe- 
ritic poison does not therefore, like that of scarlet fever, exhibit any 
marked tendency to increase the animal heat. Even in profound and fatal 
blood poisoning in this disease, the thermometer shows the normal, or 
scarcely more than normal, temperature, so that the inexperienced practi- 
tioner is apt to be deceived in his prognosis. On the other hand, a con- 
tinued elevation of temperature with only moderate angina should lead 
the physician to examine for some complication, perhaps a nephritis. 

The tongue is usually moist, and slightly furred. The patient often 
vomits in the commencement, and if this cease or be seldom repeated, it is 
not a grave sign ; but vomiting occurring often, so that the food is rejected, 
and due often no doubt to uraemia, is not infrequent in severe cases. The 
appetite varies. Repugnance to food characterizes many of the gravest 
cases, and, if the child be compelled to take it, it is often rejected by 
vomiting. There are no notable symptoms referable to the state of the 
intestines. The stools usually appear normal, except as they are changed 
by medicines. 

The respiratory apparatus is not involved in the benign cases in which 
only the fauces are inflamed. But next to the fauces and posterior buccal 
surface, the Schneiderian membrane is most frequently affected of all the 
surfaces, and when the nares are inflamed, and are covered to a greater or 
less extent by the pseudo-membrane, there is more or less discharge, which 



274 DIPHTHERIA. 

may excoriate the upper lip, and cause incrustation around the entrance of 
the nostrils. This often renders respiration through the nostrils difficult. 
In cases having this severity there is usually at the same time considerable 
faucial swelling, so as to cause guttural respiration, which is most marked 
in sleep. But the most important symptoms pertaining to the respiratory 
apparatus, occur when the inflammation attacks the laryngeal surface, or 
this surface and those contiguous to and below it in the respiratory tract. 
Diphtheritic croup may be primary or secondary. In New York the 
secondary form most frequently occurs as a complication of measles, and 
as the rubeolar inflammation extends not only over the larynx and trachea, 
but bronchial tubes, the diphtheritic pseudo-membrane is apt to extend 
further downward than when the inflammation is primary. 

Diphtheritic croup often occurs at the commencement of diphtheria, so 
as to be and continue to be the predominant inflammation, but in other 
cases it supervenes after diphtheria has continued a few days. There 
are many mild cases, which give no anxiety so long as the inflammation 
remains faucial, but in which the whole aspect is within a day changed by 
the occurrence of croup, and the condition becomes one of imminent 
danger. Usually when diphtheritic croup occurs there is a simultaneous 
if not pre-existing exudation upon the fauces. Occasionally in undoubted 
diphtheria the diphtheritic pellicle forms only upon the surface of the air- 
passages below the epiglottis, while the fauces present merely an inflam- 
matory reddening, and the surface of the nares is either free from disease 
or only reddened. Thus in January, 1875, I attended a child, aged two 
years and ten months, who died from a gradually increasing dyspnoea after 
a sickness of four days, having during his sickness moderate swelling of 
the tonsils, and general redness of the faucial surface, but without mem- 
branous exudation upon it. The symptoms and history of the case were 
precisely those of true croup, but the diphtheritic nature of the malady 
was clearly shown by the occurrence very soon after the death of the pa- 
tient of diphtheritic pharyngitis with the characteristic exudation upon 
the fauces, of the two young women who nursed him. 

In New York, as will be seen by the table below, the predominant in- 
flammation in about one fourth of the cases of diphtheria is the laryngitis. 

In addition to the accelerated pulse during the febrile stage and the slow 
and compressible pulse during the stage of profound blood poisoning, the 
chief symptoms, pertaining to the circulatory system, relate to the state 
of the heart, and the altered state of the blood which gives rise to haem- 
orrhages. The ante-mortem heart-clots, the weakened action of the heart 
from degenerated muscular fibres, the haemorrhages from the altered state of 
the blood, indicate a very dangerous condition of the circulatory apparatus. 

Very little attention had been bestowed upon the state of the kidneys, 
and the character of the urine in diphtheria, till Mr. Wade, of Birming- 
ham, discovered albuminuria, since which many observations in different 



SYMPTOMS. 275 

epidemics, and localities, have established the fact that albuminuria occurs 
in a majority of cases of a severe type, and in many cases of diphtheritic 
laryngitis in which the type is not severe. Two conditions of the kidneys 
give rise to albuminous urine, namely, nephritis, which is the most com- 
mon, and venous congestion, which occurs in cases of embarrassed circula- 
tion, as in certain cases of diphtheritic laryngitis, and in obstruction from 
heart clots. The latter is comparatively infrequent. 

During the latter part of 1875, and in 1876, prior to August 1, I en- 
deavored to obtain and examine the urine in every case of idiopathic 
diphtheria, having a clear diagnosis, which came under my notice, both 
in family practice and in the institutions with which I have an official con- 
nection. Ordinarily, during the first week of a case, I found that the 
urine deposited urates on cooling, and that the nitric acid test showed a 
large relative quantity of urea, but I suspect that this was due to a some- 
what diminished quantity of urine. But the occurrence of albumen was 
of chief interest, and the results of the examinations as regards the presence 
or absence of this, are recorded in the accompanying table. In most of 
the cases the urine was examined several times in the course of the dis- 
ease, and, if albumen were present, a microscopic examination was also 
made. In nearly all the specimens which contained albumen — all but 
three or four — casts, usually granular, but now and then hyaline, and 
sometimes both kinds in the same specimens, were observed. In those 
cases of albuminuria which recovered, there were comparatively few 
casts, or none. If the albumen were abundant, and casts plentiful, the 
case was usually fatal, though not perhaps till after the lapse of three or 
four weeks, when death occurred with symptoms of exhaustion, paralysis, 
or feeble heart-action, sometimes with oedema of lungs supervening sud- 
denly, and, probably, formation of heart clots. The albuminuria, unlike 
that of scarlet fever, seldom occurred except in the grave cases ; and in 
the majority of instances it did not appear till near the close of the first 
week, or in the second, and, in a few instances, not till a later period. 
Although the albuminuria of diphtheria is much more grave than that of 
scarlet fever, it has in my practice been attended by much less serous 
effusion or dropsy, often by none which was appreciable. The urine, 
although containing a large quantity of albumen, ordinarily had nearly the 
normal appearance, instead of the smoky or hazy color so common in the 
albuminous urine of scarlet fever. 
I. Cases attended with the usual membranous exudation upon the fauces, 
with or without coryza, and without laryngitis or with only catarrhal 
laryngitis ; fifty-eight cases. 



With albuminuria, 
Without albuminuria, 
State of urine not recorded, 



Died. 


Recovered. 


Result not 
stated. 


Total. 


13 


5 


1 


19 


4 


27 


1 


32 


3 


4 




7 



276 DIPHTHERIA. 

II. Cases attended with membranous laryngitis as the predominant in- 
flammation ; nineteen cases. 

Died. Recovered. Total. 

Witli albuminuria, . . 4 1 . . 5 

Without albuminuria, .2 4 . . 6 

State of urine not recorded, .7 1 . . 8 

The mortality of the cases embraced in the above table was probably 
larger than the average in New York practice, for several of them were 
seen in consultation, and their type was severe. Those in which the 
state of the urine could not be ascertained, were usually in children so 
} 7 oung or so near death that it was impossible to obtain sufficient urine for 
examination. 

It is seen that in New York, where diphtheria is endemic, of 62 cases 
occurring in the course of about ten months, 24 were attended by albumi- 
nuria, and 38 were exempt. In a larger number of cases, of which I 
have preserved the records since 1876, I think that the proportion of al- 
buminous cases has been about the same, but obviously during epidemics 
of a severe type, the proportion is larger than when the type is mild. 

An efflorescence is sometimes observed upon the skin during the time 
in which the temperature is exalted. It is the erythema fugax of derma- 
tologists, suddenly appearing and disappearing. This eruption, which is 
so common in the febrile and inflammatory affections of childhood, does 
not seem to present any peculiar characters in children. But there is 
another eruption, which I have several times observed, and of which I 
have preserved a drawing as it appeared in one case, which I have no 
doubt is due to diphtheritic toxaemia, or to septicaemia occurring in diph- 
theria. It appears after the sixth or seventh day, in the form of red 
points or spots, not more than a line in diameter, and interspersed with 
patches of larger size, and irregular margins, one to two inches in diame- 
ter. This roseolar eruption is slightly raised, like that of measles ; it dis- 
appears on pressure, and so far as I recollect, it has, in my practice, ap- 
peared only in fatal cases. Occasionally extravasations of blood occur 
in and under the skin, like those in the internal organs. The pal- 
lor of the skin, which diphtheritic toxaemia produces in the second and 
third weeks, is known to all who have had experience with this disease. 

Diphtheritic paralysis is described by some writers as a symptom and by 
others as a sequel. It usually begins during convalescence in the second 
or third week after the abatement of the inflammatory symptoms, but 
sometimes not till a later stage. It may on the other hand appear con- 
siderably earlier, during the stage of the development of the inflammations, 
as early as the fifth or sixth day, or even as early as the second or third day 
from the beginning of the diphtheria (Sanne). When the paralysis begins 
at an early period it may cease, and reappear later, and in other parts. Its 



SYMPTOMS. 277 

commencement may not be announced by any symptoms apart from the 
loss of muscular power, but in other cases there is febrile movement with 
albuminuria. The muscles most frequently affected are those of the phar- 
ynx, and upper part of the larynx. The muscles of deglutition are some- 
times so involved, that the food and drinks are not swallowed till after 
several successive efforts, and a part may be returned through the nostrils. 
A portion of the food sometimes enters the larynx, so as to produce vio- 
lent coughing. As we observe the dysphagia, it seems as if there must 
be pharyngitis, which renders deglutition difficult, but on inspecting the 
fauces we find no evidence of inflammation. The mucous membrane has 
recovered its normal appearance, and the nerves only are affected. The 
velum palati hangs flaccid and motionless like a curtain ; and the relaxed 
state of the muscles at the entrance of the larynx, causes guttural respira- 
tion, or snoring in certain cases, which is especially marked during sleep. 
In severe cases the difficulty of swallowing may endanger suffocation from 
the lodgment of food in the larynx, and inspire dread of taking food on the 
part of the child. Tickling, and even pricking the velum fails to induce 
motion. In some there is only faucial paralysis, but in many the loss of 
muscular power occurs in other parts also. Whenever it occurs elsewhere, 
the pharyngeal muscles are nearly always involved at the same time. 
Diphtheritic paralysis may affect the motor muscles of the eye, causing 
strabismus ; the muscles of one side, causing hemiplegia ; of the legs, 
causing paraplegia ; or of an arm on one side and leg on the opposite. It 
does not commence simultaneously in the various muscles which are 
affected, but in succession, those first affected being for the most part 
the muscles of the pharynx. In some patients the muscles of the bladder 
are paralyzed, leading to retention of urine or difficulty in passing it. 
Paralysis in the limbs is frequently preceded by tingling or a sensation of 
formication. There is often not a total loss of sensation or of motion in 
the paralyzed part, but more or less numbness with difficulty rather than 
impossibility of motion. A few cases have been reported in which the 
paralysis was almost general, and some believe that they have met cases 
in which the heart was paralyzed, death occurring suddenly and unex- 
pectedly. Dr. J. B. Reynolds relates a case in the New York Journal of 
Medicine, May, 1860, in which there were not only strabismus, partial 
paralysis of the limbs, and paralysis of the muscles of the pharynx, so 
that food was regurgitated, but the head dropped forward so that the 
chin rested on the sternum. 

A majority of those affected with paralysis recover, although few regain 
the complete use of their muscles in less than one month, and many do 
not till between two and four months. 

Defect of vision is an occasional result of diphtheria ; some have pres- 
byopia ; others myopia ; some see double ; some are amaurotic ; while in 



278 DIPHTHERIA. 

others one pupil is more dilated than the other, or both pupils are dilated, 
and feebly sensitive to light. This impairment or perversion of vision 
gradually disappears as the vigor of system returns. 

Various theories have been advanced in explanation of the occurrence 
of the paralysis, as that of reflex irritation advocated by Brown-Sequard, 
that of anaemia, etc. A careful examination of the nervous centres, 
made in certain fatal cases, has revealed nothing which throws light on 
its etiology. That the diphtheritic virus causes paralysis by some special 
action is evident, for there is no other infectious disease which is attended 
and followed by paralysis so often as diphtheria. The most plausible 
theory is that recently brought to light by histological examinations, which 
have shown that the peripheral nerves in paralyzed parts have undergone 
degenerative changes, as mentioned above, so that under the neurilemma, 
we observe more or less granular matter, in place of the normal nerve 
tissue, or lying in this tissue. Among the many anatomical changes 
which the specific principle produces, those in the peripheral nerves 
must therefore be regarded as important, since pathological changes in the 
nerves which supply paralyzed muscles sanction the belief that they sus- 
tain a causative relation to the paralysis. 

Diagnosis. — In most instances the diagnosis of diphtheria is readily 
made when the case has continued a few hours, for the characteristic false 
membrane is observed on inspection of the fauces. I have usually at my 
first visit been able to state the nature of the pharyngitis from its appear- 
ance. But there are cases which vary from the typical form in which the 
diagnosis is more or less difficult. The confervoid growth of sprue, when 
occurring upon the fauces, is sometimes mistaken for the false membrane 
of diphtheria, but the error of mistaking one for the other in cases which 
I have met, has been due to hasty and careless examination rather than 
to any real difficulty in the discrimination. The peculiar product of> 
sprue has but little depth and coherence, and is readily detached without 
injury to the mucous membrane or its vessels. If there be any doubt, the 
differential diagnosis can be readily made by the microscope. 

Follicular pharyngitis, like diphtheria, commences with sharp fever, 
which, however, is ephemeral, and is attended with the formation of round 
white masses in the site of the follicles, usually over the tonsils only. 
These masses do not occur in patches, like those of diphtheria, except 
when two or three are in close proximity and unite, but at the same time 
a sufficient number are discrete to establish the diagnosis. Follicular pha- 
ryngitis often occurs in several members of a family at the same time, in- 
volves no danger, and is quickly cured. The white masses consist of the 
inspissated secretion of the follicles mixed with epithelial cells. 

The diagnosis of diphtheritic from membranous laryngitis is often diffi- 
cult. Diphtheritic laryngitis is usually accompanied by more tumefaction 
of the lymphatic glands of the neck, and more discharge from the nostrils. 



DIAGNOSIS — PROGNOSIS. 279 

Moreover the laryngitis is often secondary in point of time to the pharyn- 
gitis, so that in the first day of the former we observe so much faucial 
inflammation, that it is evident that the latter predominates ; whereas in 
true croup, the laryngitis precedes and predominates. 

Often the diagnosis is made clear by the history. Thus a boy, aged 
two years and ten months, died of acute laryngo -tracheitis, lasting 
about four days. He lived in the suburbs of the city, where the houses 
were scattered, and where there had been no recent diphtheria. The 
case commenced with hoarseness, which gradually increased to a fatal 
obstruction in the air-passages, without any pseudo-membrane upon the 
fauces or upon any other visible part. This case seemed to be identical 
with the true croup with which we were familiar before the occurrence of 
diphtheria in New York ; and yet it was diphtheritic, for two or three 
days after the death of the child, two nurses who attended him were 
affected with severe diphtheritic pharyngitis with the characteristic 
pseudo-membrane. 

Sometimes the occurrence of albumen in the urine, with or without 
fibrinous casts, aids in establishing the diagnosis, for it is more common 
in diphtheria than in croup. It is evident, from the above facts, that the 
diagnosis of diphtheritic from membranous croup, though possible in typi- 
cal cases, in localities where diphtheria is not endemic or epidemic, is 
difficult if not impossible at the bedside in localities where diphtheria pre- 
vails, especially when there is little or no exudation upon the fauces. 

Prognosis. — No infectious disease presents greater differences in type 
or severity. In mild epidemics, with moderate fever, slight faucial swell- 
ing, and little extent of the pseudo-membrane, a large majority recover, 
and would recover even without treatment. Uncertainty of prognosis, of 
which even physicians of ample experience complain, is largely due to 
the fact that diphtheria terminates fatally in several distinct ways. Hence 
while the patient may be secure as regards the more manifest and common 
conditions of danger, so as to justify a favorable prognosis in the opinion 
of the physician who attends him, the fatal result may suddenly occur 
from some unseen and unsuspected cause. 

Death in diphtheria may result from — 

1st. Diphtheritic blood-poisoning. 

2d. Probably, also, from septic blood-poisoning produced by absorption 
from the under surface of the decomposing pseudo-membrane. But it is 
difficult to distinguish the constitutional effects of sepsis from those pro- 
duced by the diphtheritic poison. Septic poisoning is obviously most 
apt to occur in those cases in which the pseudo-membrane is extensive, 
and deeply imbedded, and its decomposition attended by an offensive 
•effluvium. Cervical cellulitis, and adenitis, which, when severe, cause very 
considerable swelling of the neck, appear to be often, if not usually, due to 
septic absorption from the faucial surface, the inflammation extending 



DIPHTHERIA. 

from the absorbents to the glands and connective tissue. Considerable 
tumefaction of the neck, therefore, seldom occurs in diphtheria or scarlet 
fever, without manifest symptoms of toxaemia, and is to be regarded as a 
sign of its presence. 

3d. Obstructive laryngitis. 

4th. Uraemia. 

5th. Sudden failure of the heart's action, either from the anaemia, and 
general feebleness, from granulo-fatty degeneration of the muscular fibres 
of the heart, which is liable to occur in all infectious diseases of a malig- 
nant type, or from ante-mortem heart clots. 

6th. Suddenly developed passive congestion and oedema of the lungs r 
probably due to feebleness of the heart's action, or to paralysis of the res- 
piratory muscles. I have known death to occur apparently from this cause- 
during the period of supposed convalescence, and when the visits of the' 
physician had been discontinued. Thus in a case in my practice, symp- 
toms of oedema pulmonum (moist rales in both sides of the chest,, and em- 
barrassed breathing) suddenly occurred nearly ODe month after the disap- 
pearance of the faucial pseudo-membrane and inflammation. The urine,, 
which had contained considerable albumen during the active period of the 
malady, had for some time shown no trace, or but slight trace of this prin- 
ciple by the proper tests. By active stimulation these symptoms entirely 
disappeared in a few hours, and the heart's action seemed normal, unless- 
a little weakened. On the following day the same symptoms reappeared,, 
and death occurred before I was able to reach the house. 

That physician obviously is least apt to err in prognosis, who recognizes- 
the fact that patients are liable to perish in any of these different ways, 
and carefully examines in reference to all the conditions which involve- 
danger. Many physicians, as I have had the opportunity to observe, are 
remiss in not examining more frequently the urine of diphtheritic patients, 
for there is often a large amount of albumen in the urine in diphtheria, 
indicating a poisonous quantity of urea in the blood, and yet the appear- 
ance of the urine to the naked eye is probably normal. 

Among the symptoms which render the prognosis unfavorable are,, 
repugnance to food, vomiting, pallor of countenance, with progressive 
weakness and emaciation from the blood-poisoning ; a large amount of 
albumen with casts in the urine, showing uraemia, to which the vomiting 
is sometimes, but not always, attributable ; a free discharge from the nos- 
trils, or occlusion of them by inflammatory thickening, and exudation, 
showing that a considerable portion of the Schneiderian membrane is in- 
volved, haemorrhage from the nostrils or fauces, and obstructed respiration. 
In diphtheritic laryngitis, attended by obstructed respiration, a large ma- 
jority have thus far died, whether treated by the most approved inhala- 
tions or by tracheotomy. One, at least, of the above symptoms has been: 
present in most of the fatal cases which I have observed* 



TREATMENT. 281 

Treatment. — Although diphtheria has been one of the most common of : 
the severe infectious maladies in this country during the last twenty -five 
years, physicians are far from agreeing in reference to the proper mode 
of treatment. This difference of opinion respecting the therapeutic re- 
quirements is due in part to difference in the type of the malady in differ- 
ent localities and epidemics, in part to difference in diagnosis, so that one 
considers a case to be diphtheritic, which another regards as a non- 
specific inflammation, but more to the fact that different theories are held 
respecting the cause and nature of diphtheria. Scarcely any other dis- 
ease presents such a diversity in type as diphtheria, from cases, so mild 
that nearly all recover, whatever the measures employed, to those so severe 
that a large proportion die under the best possible treatment ; and this 
difference in type may be observed in cases occurring at the same time 
in a great city like New York, and even in the cases which two physi- 
cians practising near each other may be called to treat. Hence one 
physician recommends with confidence a medicine or mode of treatment 
as eminently successful in his hands, which another speaks disparag- 
ingly of. 

The germ theory, described above, according to which diphtheria is 
produced by micro-organisms, has in my opinion had a harmful effect 
on the therapeutics of this malady. Acceptance of the germ theory does 
not require us to believe that diphtheria is primarily local, for these or- 
ganisms might enter and infect the blood through the lungs, before any 
symptom occurred, but as it is ordinarily promulgated, we are taught 
that these organisms alight upon one of the exposed surfaces, usually the 
fauces, where they excite local inflammatory action, and if not promptly 
destroyed, are very apt to penetrate the tissues, enter the blood, and es- 
tablish a constitutional disease. Acceptance of this theory evidently leads 
to the employment of germicide medicines, the so-called antiseptics, or 
anti-ferments, externally and internally, to arrest and destroy the vege- 
table growth, their local use sufficing, according to the theory, in the 
early stage, when these organisms have passed no further than the sur- 
face, but their internal use being required in addition, if the malady have 
continued longer, and the disease have become general. Hence, in pro- 
portion as this doctrine came in vogue, carbolic acid, chlorine prepara- 
tions, bromine, the sulphites, phenic acid, and, as the best representative 
of this class of medicines, and most powerful antiseptic, salicylic acid, 
attained at once prominence as the agents which would be most likely to 
cure diphtheria, by destroying the cause. A solution of bromine and 
bromide of potassium, having been used, with apparent good results, in 
the antiseptic surgery of the army during the late war, has obtained under 
the influence of this theory some reputation in New York as a remedy 
for diphtheria, employed externally and internally, and without the aid 
of other therapeutic agents. A certain number of drops are administered 



282 DIPHTHERIA. 

internally every hour, or second hour, properly diluted, and the same 
medicine undiluted, or with less dilution, is applied to the fauces with a 
brush at regular intervals. 

But experience, if sufficiently extensive, is the safe guide in therapeu- 
tics, and, according to my observations, internal antiseptic measures have 
not seemed to exert any marked controlling effect on the course of diph- 
theria. 

Thus in Case IV. related above, a child of four years took, almost 
from the beginning of the sickness, a mixture of potassa and iron on the first 
hour, two grains of quinine on the second hour, and three grains of sali- 
cylic acid on the third hour, and this treatment was continued night and 
day ; and yet this child, having from the first taken sixteen grains of qui- 
nine, twenty-four of salicylic acid, besides the potash and iron daily, died 
after eight days with profound blood poisoning, having had many extrava- 
sations of blood. 

This case, which presented the ordinary history of fatal diphtheria, did 
not seem to be materially modified by the internal antiseptic treatment. 
It would apparently have done as well without it. It is but one case, 
though an average example, and I have not observed any other in which 
the internal use of antiseptics seemed e to produce a curative effect. My 
knowledge, however, of the bromine treatment is limited to the four chil- 
dren of one family, and to the effects of its use, which have been reported 
to me by others. 

The theory that micrococci, or vegetable monads, are the specific prin- 
ciple of diphtheria, which suggests and justifies the antiseptic treatment, 
was promulgated to the profession by those who had seen less of diph- 
theria than many others, but had zealously used the microscope. 
Their opinion, based on microscopic examinations and experiments, plausi- 
ble, because having the appearance of scientific exactness, was widely rer 
ceived. And since, according to this theory, diphtheria is at first localized 
at the point upon the surface where the micrococci are received, this opin- 
ion, so far as it was accepted, evidently led to the early energetic treatment 
of the local ailment, and indifference as regards constitutional measures. It 
is interesting to observe how the profession have been led by theories to 
regard the local treatment of diphtheria as of prime importance, especially 
during the first stage of the malady. About thirty years ago, when 
Trousseau was making his observations on diphtheria, and his views had 
great weight with the profession in both continents, it was believed that 
those blood diseases, which were communicated by inoculation, were at 
first local, even after the specific inflammation had appeared at the point 
•of inoculation. Syphilis, for example, could be cured, it was thought, by 
proper applications to the specific eruption, if made within a certain number 
of days, and before the poison had entered the blood. In the same way it 
was believed that diphtheria is commonly received by inoculation, as it 



TKEATMENT. 2S3 

confessedly sometimes is, and could be cured by early applied local meas- 
ures. Hence Trousseau recommended to attack the pseudo-membrane, 
with what he designates ' ' savage energy. ' ' After a time it began to be 
believed that the acute infectious diseases are already constitutional, al- 
though contracted by inoculation, when the specific eruption or lesion has 
appeared upon the surface, and that therefore no local treatment can pre- 
vent blood contamination, since it is already present. Now, when this 
opinion was received generally by the profession, and diphtheria began to 
be regarded a constitutional malady, in its inception, as much as scarlet 
fever or measles, the promulgation of the bacterian theory exerted a retro- 
grade influence, so that it seemed for a time, as if the old mode of treat- 
ment of the age of Bretonneau, and Trousseau, would be restored. At 
this time there appeared in our language the elaborate volumes of Ziems- 
sen's Encyclopedia, and as the authors of these volumes are for the most 
part patient and exhaustive investigators, these volumes occupied the 
centres of our private libraries, and were pointed out as the means which 
would be likely to elevate the profession of this country to a higher stan- 
dard of medical knowledge. The treatise on diphtheria contained in this 
encyclopedia, the most minute of any on this subject in the English lan- 
guage, was eagerly sought for and read, and an immense amount of harm 
done. The writer of this treatise is fully committed to the bacterian 
theory, and the section relating to treatment begins thus : "In diphtheria 
we have to deal at first with an infection, which is localized, and after- 
ward with a general disease resulting from this, out of which may ulti- 
mately be developed still later affections of various organs," and he dis- 
cusses first the local treatment as of paramount importance, and, secondly, 
the general treatment. It was a great misfortune, that a treatise like 
that by Sanne had not appeared in place of the one published. But 
the mischief was done, the brush and inhalations were made the potent 
instruments of cure, and constitutional remedies held the second place, and 
were believed to be unnecessary, except when local treatment had failed 
to destroy the micrococci, and the second stage, or that of general infec- 
tion had arrived. For a time this theory has had its influence on prac- 
tice, but unpleasant experiences have taught, and are teaching, physicians, 
that local measures, however early and perseveringly employed, do not 
protect the system from the diphtheritic poison, do not prevent the occur- 
rence of unmistakable symptoms of general infection in all cases of a grave 
type. Whatever the theory, experience gradually establishes the fact, in 
the minds of all observing physicians, that constitutional treatment is of 
paramount importance in diphtheria, as it is in that other malady, which, 
in my opinion, is most nearly akin to it, namely, scarlet fever, except 
when the danger is located in the larynx. 

Between December, 1875, and July, 1878, I examined minufely, and 
preserved records of, 104 cases of primary diphtheria, occurring either in 



284 DIPHTHERIA. 

my private practice, or seen by me in consultation, besides observing cases r 
and witnessing autopsies in the New York Foundling Asylum, where diph- 
theria was endemic nearly two years. From these observations, and 
from the many cases which I have since observed, I am persuaded that, in 
order to secure the best treatment, constitutional and local, of diphtheria, 
it is necessary that the physician should accept the following proposi- 
tions : 

1st. The specific principle of diphtheria, in all probability, enters the 
blood, in ordinary cases, through the lungs ; and after an incubative pe- 
riod, which varies from a few hours to seven or eight days, produces the 
symptoms which characterize the disease. 

2d. As in vaccinia the system is infected as soon as the vaccine erup- 
tion appears, so in diphtheria the blood is infected as soon as the pharyn- 
gitis and pseudo-membrane occur. Their intimate relation to the circu- 
latory system, and especially the fact that raising the pseudo-membrane 
lacerates capillaries, and causes bleeding, prevents our believing otherwise. 

3d. The blood poisoning is probably sometimes septic, but as it ordin- 
arily occurs, it is produced by a specific principle peculiar to diphtheria. 

4th. Facts do not justify the belief that the system can be protected 
by antiseptic or preservative medicines administered internally. A quantity 
of this kind of medicine, introduced into the system, sufficient to preserve 
the blood and tissues from the action of the diphtheritic virus, would, 
there is every reason to think, be so large as to arrest molecular action, 
and therefore the functions of organs, and occasion death. 

5th. There is no known antidote for diphtheria, in the sense in which 
quinia is an antidote for malarial diseases, and no more probability that 
such an antidote will be discovered than for scarlet fever or typhoid fever. 

6th. Diphtheria, like erysipelas, has no fixed duration. It may cease 
in two or three days, or continue as many weeks ; but the specific poison 
acts with more intensity in the commencement than subsequently, and its 
energy gradually abates. Hence, diphtheritic inflammation, which arises 
in the beginning of diphtheria, as laryngitis, is more severe and dangerous 
than when the malady has continued a few days. 

7th. The indication of treatment is to sustain the patient by the most 
nutritious diet, by tonics, and stimulants ; and to employ other measures, 
general and local, as adjuvants, to meet special indications which may 
arise. The rules of treatment appropriate for scarlet fever, apply for the 
most part to diphtheria. Local treatment of the inflammations should be 
unirritating, and designed to prevent putrefactive changes and septic 
poisoning. Irritating applications which produce pain lasting more than 
a few minutes, or which increase the area or degree of redness, are apt to 
do harm, and increase the extent and thickness of the pseudo-membrane. 

General Treatment. — This may be conveniently considered under the 
three heads, food, stimulants, and tonics. All physicians of experience 



STIMULANTS, 285 

recognize the importance of the use of the most nutritious and easily 
digested food, and the preservation of the appetite — for the safety of the 
patient requires that he should retain, so far as possible, his flesh and 
strength. The more nutritious and easily digested the food, given in suffi- 
cient quantity, with the appetite preserved, the less, obviously, the danger 
of the fatal prostration, which so frequently occurs suddenly and unexpect- 
edly in grave cases. Beef -tea, or the expressed juice of meat, milk with 
farinaceous food, etc., should be administered every two or three hours, or 
to the full extent, without overtaxing digestion. Failure of the appetite, 
and refusal to take food, are justly regarded as very unfavorable signs. 
One objection to the use of the brush, instead of spraying the fauces with 
the atomizer, is that it is more apt to provoke vomiting, by which nutri- 
ment, that is so much required, is lost. In malignant cases of diphtheria, 
as in scarlet fever of a similar type, patients are sometimes allowed to 
slumber too long without nutriment. It is the slumber of toxaemia, and 
should be interrupted at stated times, in order to give the food. 

Stimulants. — M. Sanne, in his elaborate treatise on diphtheria, says : 
'" De tous les antiseptiques donnes a l'interieur, l'alcool est de beaucoup 
le plus sur. Plus 1'infection est prononce, plus il faut insister sur les com- 
poses alcooliques. " He states that Bricheteau reports the history of a 
patient, who took daily, during the diphtheria, a bottle and a half of the 
wine of Bordeaux, without the least symptom of intoxication or headache. 
A somewhat similar case was reported to me, in which nearly a bottle of 
brandy was given in less than twenty-four hours, without any ill effect, 
and an apparent good result on the general course of the disease. The 
same rule holds true in diphtheria as in other acute infectious maladies, 
that while mild cases do well without alcoholic stimulants, they are re- 
quired in cases of a severe type, and should be administered in large and 
frequent doses, whenever pallor and loss of appetite, or of strength and 
flesh, indicate danger from the diphtheritic or septic infection. It matters 
little how the stimulant is administered, whether milk-punch or wine- 
whey, provided that the proper quantity is employed. Dr. E. N. Chap- 
man, of Brooklyn, a physician of large experience, considers alcohol 
almost a specific for diphtheria. I believe, from my observations, that, 
if given early and frequently in grave cases, as, for example one teaspoon - 
ful every half hour of brandy or Bourbon whiskey, it does have a ten- 
dency to render the disease more tractable, and that it therefore affords 
important aid in saving the patient's life, and I am willing to allow that 
it is as nearly a specific as any other agent. But to be instrumental in 
saving life in malignant cases, it must be given boldly from the start. 
If there be marked diphtheritic toxamiiawhen its use is commenced it will 
not save life, but it may prolong it. Although an advocate of the liberal 
use of alcohol I cannot regard this agent as a specific. When I com- 
menced serving in the New York Foundling Asylum in May, 1878, the 



2S6 DIPHTHERIA. 

quarantine wards contained four children, between the ages of three and 
five years, who had been sick a few days with severe diphtheria, and it 
was evident at a glance that they must soon perish with the ordinary mild 
sustaining treatment. Quinine, iron, the most nutritious food, and a mod- 
erate amount of alcoholic stimulants were being given, and Ave determined 
to increase the Bourbon whiskey to one teaspoonful every twenty to thirty 
minutes, day and night. Nevertheless, whatever the result might have 
been with the earlier commencement of this treatment, the blood poison- 
ing was now too profound, and one after the other died. That intoxica- 
tion is so seldom produced in this disease by frequent and large doses of 
the alcoholic compounds is due partly to the quick elimination of such sub- 
stances from the system, and in part, probably, to the nature of diphtheria. 
In fulfilling the indication for sustaining treament, the vegetable tonics 
have been long used, especially cinchona and its alkaloid principle quinia. 
The compound tincture of cinchona, and the fluid extract, have been used 
and recommended by physicians of experience ; but of vegetable agents, 
quinia has long been and still is more frequently prescribed than all others. 
But the doses employed vary greatly in size and frequency, in the prac- 
tice of different physicians. It is administered in large doses for its anti- 
pyretic effect, so that twenty or thirty grains are given daily, and in small 
doses, as one to two grains every fourth hour, for its tonic effect. That 
there is nothing antagonistic in the action of quinine to the diphtheritic 
virus, and that it is beneficial in the same way, and no further, than in 
other acute infectious diseases is, I think, generally admitted by the pro- 
fession. Large and frequent doses apparently produce no amelioration 
in the severity of the disease, or diminish the degree of blood-poisoning, 
as is shown by cases like the following, which are not infrequent during 
severe epidemics. 

C, aged four years, male, was examined by me in consultation, on 
February 3 0th, 1876. I learned that he had apparently contracted diph- 
theria from the escape of sewer-gas through a defective trap in the little 
room where he slept, and that the disease began after midday on 
February 6th, with fever. At 10 P.M. of the same day, when visited by 
the family physician, the temperature was 103°, and the fauces were red, 
but without any pseudo-membrane. Four grains of quinia were ordered to 
be given every two hours, and ten drops of the tincture of the chloride of 
iron, with two grains of the chlorate of potassium, to be given three times 
hourly. On the 7th the exudation covered both tonsils and the half arches ; 
temperature 102^-° ; evening, temperature 100° ; pulse 128. 8th. Is 
playful ; pulse 100 ; has slight swelling of the cervical glands ; evening, 
some extension upward of the pseudo-membrane ; has vomiting. 9th. 
Pulse 144 ; vomits often. 10th. At 3 P.M. began to grow worse ; 
pharynx and nostrils covered with the exudation. From this time the 
case rapidly advanced to a fatal termination. 

It was impossible at the time of my visit to obtain the urine for exami- 
nation and death occurred a few hours afterwards. Forty-eight grains of 



STIMULANTS. 287 

quinia daily, administered from the first day, had no appreciable effect in 
staying the fatal progress of the malady, had no such effect as would be 
likely to follow were its action antidotal, or did it tend to prevent or 
diminish the blood poisoning. As an antipyretic, I am justified in say- 
ing from our experience in the New York Infant Asylum and New York 
Foundling Asylum, quinine is inferior to salicylate of sodium, both in 
symptomatic and constitutional fevers, but as it is a tonic, and does not 
impair digestion, it is to be preferred to any other medicine in diphtheria, 
when the febrile movement is so great that an antipyretic is needed. 
Great elevation of temperature, however, seldom occurs in diphtheria 
after the third or fourth day, for when symptoms of blood poisoning 
occur the temperature is apt to fall, so that in profound toxaemia, it is 
often not more than 101° or 102°, and the indication for quinine is 
then not for its antipyretic but tonic action. The following is a prescrip- 
tion for this agent as a tonic for a child of five years. 

I£. Quiniae sulpkat., 3 ss ; 

Elix. adjuvantis (Caswell and Hazard) ; 

or, 
Elix. tarax. comp., 3 ij. Misce. 

Give one teaspoonful every four hours. 

All physicians who are familiar with diphtheria have noticed the pallor, 
loss of appetite, flesh, and strength, which commence before the close of 
the first week in severe cases, and which are always unfavorable symp- 
toms, indicating, as they do rapid and progressive deterioration of the 
blood. The use of iron is at once suggested as the proper medicinal 
remedy to arrest this blood change, from its known effect in increasing 
the number of red blood corpuscles, and the quantity of coloring matter 
in these corpuscles, and the nutritive elements in the blood. By its effect 
on the red corpuscles, which are the carriers of oxygen, it increases the 
functional activity of organs, and improves the general nutrition. The 
ferruginous preparations, therefore, hold an important place in the thera- 
peutics of diphtheria. The one which has long stood the test of expe- 
rience, and is now commonly used, is the tincture of the chloride of 
iron. It should be given in large and frequent doses, as five drops hourly, 
to a child of three to five years. 

The inflammations, so far as they are accessible, should be treated by 
local measures, but we may combine with the iron, one which exerts a 
decidedly curative action on buccal and pharyngeal inflammations, which 
is a solvent of pseudo-membranes, and which, after it enters the system, 
being largely eliminated from the salivary glands, continues after the dose 
is taken to have effect on the inflamed surface of the buccal cavity and 
fauces. This medicine, namely, the chlorate of potassium, has of late 
years become a domestic remedy, but the laity should be cautioned in 
reference to its use. It is an irritant to the kidneys in large doses, pro- 



288 DIPHTHERIA. 

ducing intense inflammatory congestion of these organs and arresting 
their function. The melancholy fate of Dr. Fountaine more than a quar- 
ter of a century since, whose life was sacrificed by an experimental dose 
of one ounce of this agent, is remembered by the older physicians. A 
few years since in my own practice a child of about three years, with an 
active pharyngitis, probably diphtheritic, and a temperature of 103°, 
was allowed to quench its thirst between evening and morning, by 
drinking from a small pitcher in which three drachms of chlorate of 
potassium were dissolved. In the morning I was summoned in haste, and 
found the surface of the patient cold and blue, and pulse feeble. The 
urine was totally suppressed, and instead of it a few drops of blood passed 
from the urethra. Death occurred before night. The chlorate had apparently 
produced some irritation upon the intestinal surface, but the fatal result 
was evidently due to the state of the kidneys. A child of three years should 
not take more than three grains at a dose, and no more than one drachm 
in twenty-four hours. The following will be found useful prescriptions : 

I£ . Tine, ferri chloridi, 3 ij ; 
Potas. chlorat. , 3 j ; 
Syr. simplic, § iv. Misce. 
Dose, one teaspoonf ul every hour to two hours for a child of three years. In 
place of the simple syrup three parts of water arid one of glycerine may be 
employed. 

^ . Tine, ferri chloridi, 3 ij ; 

Acidi sulphurosi, 3 j ; 
Potas. chlorat., 3 j ; 
Glycerinae, 3 ss ; 
Aq. calcis, q.s. ad. ^iij. Misce. 
Dose, one teaspoonful every hour to two hours for a child of three years. 

The citrate of iron and ammonia alone, or in combination with car- 
bonate of ammonium, may be given in two-grain doses, dissolved in sim- 
ple syrup, in place of the above mixture, when the inflammation of the 
fauces has considerably abated or is moderate ; or the beef, iron, and wine 
of the shops may be given every hour or second hour. If the patient 
improve, and the disease begin to decline, the intervals between the 
doses may be lengthened, but the tonic should not be entirely discon- 
tinued until the patient is far advanced in recovery, on account of the 
dangerous sequelae, which take their origin in an impoverished state of 
the blood. 

Local Treatment. — It is important to keep in mind the purpose for 
which local measures should be employed, as stated above. It is to reduce 
the inflammation of the mucous surfaces, and destroy the diphtheritic poi- 
" son, and contagious properties in the pseudo-membrane, and to destroy the 
septic poison, and prevent its absorption, if any form. Forcible removal 
of the pseudo-membrane, irritating applications, the use of a sponge or 
other rough instrument, for making the applications, should be avoided as 



LOCAL TEEATMENT. 289 

likely to do harm. The applications should be made either with a large 
camel's-hair pencil, or, better for most of the mixtures employed, with the 
atomizer. The hand atomizer, like Richardson's hard rubber, or Delano's, 
which is of simple construction, while it carries a heavy spray from the 
curved tube, which is introduced over the tongue, is very useful. 

Half a dozen to a dozen compressions of the bulb of the hand atomizer 
cover the surface of the throat more effectually with the liquid than can 
be done by several applications of the brush, and it is usually not dreaded 
by the patient. Diminution of size of the pseudo-membrane under the 
use of the spray is a favorable sign, but if it do not diminish, its presence 
can do little harm, provided that it is properly disinfected. 

The steam atomizer may also be used, and in some cases it is more 
convenient than that worked by the hand, but the medicine employed in 
it is necessarily much diluted by the steam from the boiler, unless it be 
of such a nature that it can be used in both cup and boiler. The steam 
atomizer possesses the advantage of producing a steady spray, without 
exciting or disturbing the patient, so that it can be inhaled even during 
sleep, but it is best often to supplement its action by the hand instru- 
ment. The hand atomizer is less apt to be clogged than the delicate 
glass points of the steam instrument, and will vaporize a thicker liquid. 
This is an important advantage, especially in using the lime-water for 
inhalation in croup, since it can be employed in the hand atomizer even 
when it presents a milky appearance from the amount of lime. 

At a recent meeting of the New York Pathological Society I presented 
a specimen showing the diphtheritic exudation, and a discussion arose as 
to what is the safest and most efficient solvent of the false membrane, full 
and exact knowledge of which is very important, especially for correct 
treatment of diphtheritic croup. Chlorate of potassium, pepsin, lactic acid, 
and lime, are solvents of pseudo-membranes, and after the meeting of 
the Pathological Society Dr. Chadbourne, resident physician of the New 
York Foundling Asylum, and myself, determined to ascertain experimen- 
tally which is the best solvent. We employed reliable liquid pepsin, acid- 
ulated with lactic acid, thirty drops to the ounce, for one solvent, and 
the officinal lime-water for the other. Equal portions of pseudo-mem- 
brane, removed from the larynx in a fatal case of diphtheritic croup, were 
added to the same quantity of these liquids. The-lime water produced 
complete solution in about twenty-five minutes, while the lactic acid and 
pepsin required more time. I have repeated the experiment since, with a 
similar result, and have employed the lime-water mixed with about one- 
fourth its quantity of carbonic acid water, but this did not seem to im- 
pair materially the solvent power of the lime. This last experiment was 
made in order to determine whether the carbonic acid, which passes over 
the pseudo-membrane in each expiration, impaired the solvent action of 
the lime. 



290 DIPHTHERIA. 

Therefore in the local treatment of diphtheritic pharyngitis, plain 
lime water is one of the best solvents of the pseudo-membrane used by 
the atomizer or gargle, preferably by the former, or one of the follow- 
ing mixtures may be employed : 

No. 1. 
]J. Acid, carbolic, 3ss; 

Aquae calcis, | viij. Misce. 

No. 2. 
IJ . Acid, carbolic, 3 ss ; 
Potas. chlorat., 3 iij ; 
Glycerinae, | ij ; 
Aquae, | vj. Misce. 

More recent investigations, conducted by Dr. Chadbourne, have shown 
that liquor potassse, or liquor sodas, one part to forty of water, is a still 
more active solvent of fibrin. For further particulars relating to these 
investigations the reader is referred to our remarks on the treatment of 
pseudo-membranous laryngitis. 

Employ atomizer every hour or second hour. India-rubber tubing, 
which does not interfere with the action, should be drawn over the sharp 
point of Delano's atomizer. In this connection, I would state that the 
hand atomizer with double bulb is preferable to that with single bulb, 
as the child tolerates better the steady spray. The advantage of its use 
is very notable in the treatment of diphtheritic croup. 

In most cases of diphtheritic inflammation of the fauces the spray suf- 
fices for local treatment, but the following mixture, applied by a large 
camel' s-hair pencil, is also very effectual, immediately converting the 
pseudo-membrane into an inert mass, and putting a stop to all move- 
ments of the bacteria which swarm in it, as I have observed under the 

microscope : 

]J. Acid, carbolic, gtt. viij ; 

Liq. ferri subsulpliat., 3 ij-iij ; 
Glycerinae, §j. Misce. 

This may be used two or three times daily, between the spraying, or 
oftener without the spraying. It is not irritating (such an effect would 
condemn it), but it is dreaded by most children, on account of the un- 
pleasant ' ; puckering" which it produces, and the pain from the contrac- 
tion, which sometimes extends to the ear. 

That form of diphtheritic inflammation which most imperatively re- 
quires local treatment, and in which local measures are of more impor- 
tance than the constitutional, is obviously the laryngeal. Catarrhal laryn- 
gitis sometimes occurs in diphtheria, as I have occasionally observed in the 
dead-house, without producing any marked symptoms, but the pseudo- 
membranous laryngitis of diphtheria is also common, and, as all know, 
is one of the most dangerous forms of disease. 



DIPHTHERITIC CROUP. 291 



Diphtheritic Croup. 

Of the 104 cases of primary diphtheria, which I have alluded to above 
as having been seen by me in family practice, between December 1, 1875, 
and July, 1878, and notes of which I have preserved, in twenty-five the 
predominant inflammation was pseudo-membranous laryngitis. Cases in 
which there was some huskiness or hoarseness of voice, but no obstruction 
in the respiration, were not included in this number. Of these twenty- 
five cases, in which there seemed to be no reasonable doubt of the pres- 
ence of a laryngeal pseudo-membrane, nine recovered, two by tracheot- 
omy, and seven by the inhalation of the spray. Of the sixteen who died, 
upon two tracheotomy was performed, while the others were treated by 
the spray. It will be admitted, I think, that recovery of nine in twenty- 
five cases was an exceptionally good result, and was probably in part due 
to mildness in the type of diphtheria, during a portion of the time, in 
which these cases occurred, for if the type be severe, the exudation is 
more abundant, and the exudative process continues longer. But those 
who observe carefully the effects of the spray (of liquor potassae, or liquor 
soda3, one part to forty of water, or of lime-water, as the most powerful 
solvent which can be safely employed), must admit that it is the most 
effectual agent at our command for treating this very fatal affection. 
The following cases may be cited as examples, showing what may be ac- 
complished by the spray : 

L., set. 9 months, began to have croupy cough on February 16, 1877, 
but it was slight at first, so as to attract little attention. Gradually this 
symptom became worse, and on the 1 9th I was asked to see her. At this 
time both inspiration and expiration were noisy, the cough frequent and 
croupy, the temperature 101°, and the fauces red, but without any pseudo- 
membrane upon them. In addition to the internal treatment, the steam 
atomizer was ordered to be used every half hour to every hour. On the 
the 22d small patches of pseudo-membrane were observed upon the fauces, 
the noisy respiration and croupy cough remained with little change, and 
the same treatment was continued. 

24tk. Symptoms worse ; temperature 103° ; respiration still more em- 
barrassed, and the sternum is depressed in each respiration. Evening, 
temperature 101° ; respiration 40 ; pulse 136 ; urine scanty, none of 
which can be collected for examination. The steam atomizer is to-day 
substituted for the hand atomizer, and its constant use directed. 

25th. No lividity of fingers or lips, but very great dyspnoea; struggles 
for breath at times, with a wild expression of the eyes ; respiration 40 ; 
pulse 164 ; temperature 103°. On the evening of this day it did seem 
that the child would die before morning, and I greatly regretted that 
tracheotomy had not been performed, and would then have prepared for 
it, except for the opposition of the family. The steam atomizer was used 
without intermission. 

26th. Respiration 48, its character as before, but the- mother states that 
the cough is somewhat looser ; temperature 103^°. The membranous 



292 DIPHTHERIA. 

exudation has disappeared from the fauces. From this time there was 
gradual improvement, and in a few days the child was out of danger. 

In the same month in which the above case occurred, diphtheritic 
laryngitis appeared in two other families in my practice, and the following 
histories of them will also show the probable good effects of the atomizer : 

B., set. 13 months, began to be croupy on February 14. On the 16th, 
when visited by me, there were small isolated patches of pseudo-membrane 
upon the fauces, and the uvula was completely covered by this exudation. 
The cough was croupy, but the respiration was much easier than in the 
above case, and there was much less hoarseness of voice. The No. 2 
mixture was used every half hour with Delano's hand atomizer, and the 
symptoms, which never showed any immediate danger, gradually abated. 

B., a girl, set. 4 years, living in the east side of the city, began to be 
hoarse on February 14, and on the 15th the dyspnoea became so urgent 
that the attending physician performed tracheotomy. A cast two inches 
in length, circular, and evidently extending nearly to the bifurcation, was 
expectorated from the opening, after which the respiration was easier. 
Her temperature was constantly under 100°. A few days after the op- 
eration, symptoms of profound blood-poisoning occurred. The urine was 
very albuminous, and it contained casts. The edges of the opening into 
the trachea became covered with the diphtheritic pellicle, and the charac- 
teristic offensive odor was observed. Her death occurred on February 22. 

The second child, set. 20 months, began to be hoarse on February 15, 
and was visited by myself with the attending physician on the 1 7th. Her 
temperature was 101° ; her fauces were red, but with only small patches 
of exudation, and her respiration was embarrassed and noisy, so as to be 
heard in the adjoining room. We prescribed, in addition to sustaining 
remedies, the constant use of the No. 1 mixture through the steam atomizer. 
Some of the time two steam atomizers threw the spray upon the face of 
the child. It was obvious within a day or two, that the obstruction within 
the larynx had not increased, and with the constant use of the instruments 
night and day the inflammation gradually abated, and the life of the child 
was saved. 

These cases indicate, in my opinion, the proper course of treatment in 
diphtheritic laryngitis, but while we accord to local measures the first 
place in the role of therapeutic agents for this form of inflammation, in- 
ternal treatment should not, as a rule, be suspended. Even mild cases of 
diphtheritic laryngitis may end fatally by systemic infection after the ob- 
struction in the larynx is removed as in the above case, in which trache- 
otomy was performed, although the temperature during the period of the 
dyspnoea had been constantly under 100°. 

In treating diphtheritic croup, I have in some cases employed almost 
constantly the steam atomizer, which vaporizes the officinal lime-water 
without clogging, and through the glass cylinder which conveys the 
steam, have worked the hand atomizer, containing a thick or milky solu- 
tion of lime. The conjoined vapors are heavily charged with lime. I do 
not now trust to the steam atomizer alone, if lime-water be employed, 
unless in the mildest cases in which the voice is clear, and there is no ob- 



DIPHTHERITIC CROUP. 293 

struction to respiration. In obstructive laryngitis the use of the hand 
atomizer every half hour, iu addition to the steam atomizer, will save a 
certain proportion of cases from the necessity of tracheotomy, as I 
have every year had the opportunity to observe. If the tongue be 
strongly depressed by a spoon or spatula, or if the patient protrude his 
tongue, or the tongue be seized with a napkin and drawn forward, the 
epiglottis is more elevated, and the vapor more readily enters it, so as to 
immediately excite a strong cough. In a case at present under treatment, 
the patient either protrudes his tongue or I draw it forward with a napkin, 
and with every compression of the bulb of Delano's atomizer a strong- 
cough is excited, showing that the spray has entered the glottis. But 
although the spray of lime-water is a good solvent, it seems probable from 
the recent experiments, to which I have alluded, that liquor potassse, or 
liquor sodas, will yet be employed by the profession generally, for while 
it is apparently more efficient than the lime it does not clog the atomizer, 
when used in the proper proportion of one part to forty of water. 

In the New York Foundling Asylum during the last year, the resident 
physician, Dr. Chadbourne, has employed a hand atomizer with three in- 
dia-rubber bulbs, and a tip about four inches in length, with the last inch 
curved downward at aright angle. The bulbs are first distended with air, 
which is retained in them either by compressing the tubing with thumb 
and finger or by a stop-cock. The curved end of the tip is then inserted 
back of the epiglottis into the upper part of the larynx and the air allowed 
to escape. This rapidly throws a heavy vapor into the larynx, and ex- 
cites a severe cough. By this apparatus Dr. Chadbourne has succeeded 
in saving the lives of certain children which under other treatment would 
apparently have been lost. 

If the inflammation do not begin to yield, and death seem imminent, 
tracheotomy should be considered. During an epidemic of severe type this 
operation will not, with an occasional exception, save life, but when the 
type is mild a considerable proportion recover after it, with judicious 
subsequent treatment. When the type was severe in New York, and 
blood-poisoning a prominent feature, one of our surgeons operated about 
forty times, with only two recoveries, and the experience of others was 
nearly the same ; but during the last two years, with a milder type, the re- 
sult has been much more favorable. Tracheotomy should therefore be 
performed as a last resort in certain cases. 

Except in comparatively rare instances, there is only one other diphthe- 
ritic inflammation which requires special treatment, namely, that affecting 
the Schneiderian membrane. This membrane, in sensitiveness and liabil- 
ity to irritation, is intermediate between the conjunctiva and buccal or 
faucial membrane, and, therefore, when inflamed it requires milder appli- 
cations than such as are appropriate for the fauces. Applications suitable 
for the fauces would, if thrown into the nostrils, be too painful, and 



294 DIPHTHERIA. 

might increase the inflammation. I know no better treatment of the 
nostrils than to inject with a small syringe or india-rubber bulb and tip, 
one to two teaspoonfuls of the following mixture every third or fourth 
hour. It should be used at the temperature of the body, with the head 
thrown back and the eyes covered with a cloth. I have sometimes em- 
ployed it with the atomizer, its tip being covered with india-rubber tub- 
ing. 

3- Acid, carbolic, gtt. xxiv ; 
Aquae calcis, §viij. 

Diphtheritic paralysis requires the use of strychnine with tonics. I 
ordinarily employ the elix. phosphat. ferri. qui. et strychnia) of the shops. 
Each drachm of this contains gr. -gL- of strychnia, and by dilution with 
water the proper dose can be administered to a child of any age. Thus, 
recently, a child aged six years, having paralysis of the muscles of the 
pharynx, recovered in about one week, by the use of one drachm of this 
medicine daily, given in four or five doses. I have not found it neces- 
sary, in any case which I have observed, to employ electricity, but it is no 
doubt useful in expediting recovery, especially if the paralysis be in the 
limbs. The ansemic state which succeeds diphtheria requires the use of 
iron for several weeks. 

Preventive Measures. — The occurrence of diphtheria in a family 
necessitates the prompt removal of other children of the family either out 
of the house or to a distant part of it, and the disinfection of the room, 
and the handkerchiefs, and other linen, and spittoons employed. The 
diphtheritic, like the scarlatinous, virus may remain for weeks or months in 
a locality or apartment. In East Fifty-fifth Street two families resided 
in a brown-stone house, the sanitary condition of which was apparently 
good. In December, 1874, diphtheria occurred in one of these families, 
who occupied the lower floor and the basement, causing the death of two 
of the children. The other family, in order to escape the danger, imme- 
diately removed to another part of the city, where they remained two 
months, returning home on March 6th. On March 14th and loth, eight 
and nine days after the return, their two children, aged 2^- and 4-J years, 
who had been allowed free access to the room in which the fatal cases had 
occurred, also took severe diphtheria, one of them dying. 

In another family, living in the suburbs of New York, a lady con- 
tracted diphtheria from her brother's child, who died of the malady a few 
blocks distant. Returning home, she occupied a small room, remaining 
constantly in it, and by prompt local treatment was soon convalescent. 
Her only child, a boy of six years, was excluded from her companionship 
about one month, after which he was allowed to enter the room, and slept 
in it. Within a few days, namely, thirty-five days after it commenced in 
the mother, the diphtheritic patch appeared upon his fauces. In one of 
the asylums of this city, diphtheria has been prevailing more than a year, 



PERTUSSIS. 295 

the cases occurring mainly in one of the buildings, and with so little break 
or intermission that it appears that the diphtheritic virus has not been 
eradicated from one or more of the wards since the first case occurred. 
Such instances show the danger of admitting children into rooms where 
diphtheria has occurred, until a considerable period has elapsed, and 
thorough disinfection has been employed. 

When diphtheria is prevalent, indisposition on the part of a child, and 
especially febrile symptoms, or defluxion from the nostrils, should at once 
arrest attention. Although there be no complaint of soreness of the throat, 
the fauces should be carefully inspected, and if they seem too red, they 
should be sprayed with one of the mixtures recommended above. 

Pertussis. 

Pertussis is an infectious disease attended and manifested by a catarrh 
of the air-passages. This catarrh gives rise to a cough which does not 
differ, during the inception and in the declining period, from that in an 
ordinary catarrh, but during the middle period of the malady is spasmodic. 
Exceptionally the system is so mildly affected that the spasmodic element 
of the cough is lacking through the whole course of the malady, or is con- 
fined to a brief period. This distinctive symptom, namely, the peculiar 
cough, has been attributed to the irritating and disturbing action of the 
specific principle on the nerves which control the muscles of respiration. 
Some attribute it to the impression produced upon the filaments of the 
pneumogastric, especially upon those of the internal branch of the superior 
laryngeal nerve, by the mucus which collects in the larynx and trachea, 
and which is known to contain the contagious principle in abundance. 
This cough consists in a series of forcible and loud expirations, followed 
by a noisy and difficult inspiration. Its special character is due to spas- 
modic contraction of the muscles of expiration, and notably of the small 
muscles of the larynx so as to produce narrowing or even closure of the 
aperture of the glottis. Each paroxysm of the cough usually ends, not 
always, in the expectoration of viscid mucus. With rare exceptions per- 
tussis affects the same individual but once. Rilliet and Barthez report a 
case of its second occurrence, and West another case. I have attended 
two adult patients, both women of intelligence, who stated that they had 
had previous attacks in early life. Pertussis usually prevails as an epi- 
demic, but is occasionally sporadic, at which time its type is mild. It is 
highly contagious through the breath of the patient, or from exhalations 
from his surface. 

In one instance I was able to ascertain accurately the incubative period 
of pertussis. Mrs. B. having a cough for two weeks, which was after- 
ward ascertained to be that of pertussis, came from Boston to a family in 
New York. She remained with this family from 2 p.m., January 2, 



296 PERTUSSIS. 

1879, till the evening, when she left the city. During her stay she held 
and kissed an infant that was previously well, and had never been 
removed from the floor on which it was born. Pertussis was not at that 
time prevailing in New York. On the 6th, or four days after exposure, 
the infant began to cough, and this proved to be the beginning of a 
severe pertussis. 

Age. — Most cases of pertussis are between the ages of one year and 
eight years, but it occasionally occurs in adults and even old people who 
have not been attacked previously. It is rare under the age of three 
months, but through the kindness of Dr. Ewing, of New York, I was 
enabled to see a new-born infant with pertussis, whose mother had had 
the disease during the two months preceding her confinement. This in- 
fant when fifteen minutes old, and during the washing, had the first convul- 
sive seizure, which appeared to consist chiefly of a spasm of the laryngeal 
muscles, with temporary suspension of the respiration, and attended by 
deep lividity of the features, with some frothing from the mouth. These at- 
tacks occurred nearly every hour, with intervals of complete cessation of 
symptoms. The mucus between the lips finally became stained with 
blood, and death occurred on the third day. The mother, the intelligent 
wife of a clergyman, believes that the infant had similar attacks before its 
birth. A parallel case is related by Rilliet and Barthez. 

Causes. — Climate, race, and nationality do not seem to exert any de- 
cided influence on the spread of pertussis. Females are somewhat more 
liable to be attacked than males, and, as we have seen, a large majority 
of the cases occur between the ages of one and ten years. The nature of 
the contagious principle of this disease has, in my opinion, thus far eluded 
detection, and is likely to, for some time to come, on account of its sub- 
tlety. The last ten years have been characterized by very active search, 
chiefly with the microscope, for the contagia of the infectious diseases. 
Many suppose that it has been discovered, as regards diphtheria, in the 
countless bacteria which swarm in the pseudo-membrane, and even in the 
tissues and excretions, and Letzerich, about the year 1870, supposed he 
had discovered the cause of pertussis in a fungus, which received upon the 
surface of the air-passages in inspiration, increases rapidly and produces the 
spasmodic cough by its irritating effect, or the irritating property which 
it imparts to the mucus. In the first stage of pertussis he found only 
the spores of the fungus, and at a more advanced stage in addition to the 
spores he discovered the irregularly ramifying branches of the thallus. He 
introduced the mucus upon the fauces of the rabbit, and witnessed the 
production of pertussis in this animal. But a moment's thought shows us 
that this theory fails to explain the history and phenomena of this disease, 
for, unless the cause were something more subtle than the spores and 
branches of a fungus, we do not see how it is possible that the mother,, 
contracting pertussis during the last weeks of her pregnancy, should infect 



PATHOLOGICAL ANATOMY. 297 

her foetus, whose circulation is entirely distinct ; nor does this theory 
comport with the fact that pertussis passes through regular stages and 
declines, without any measures which are calculated to destroy the fungus. 
Besides, it is stated by Steffen, in Ziemssen's Ericyclopcedia, that other 
microscopists have failed to verify the theory of Letzerich. 

Lesions have been discovered in certain fatal cases which have been 
supposed to throw light on the etiology of pertussis, but which are now 
known to have been merely coincidences or results of the disease. Such 
are congestion of the spinal cord and its meninges, hyperemia of the pneu- 
mogastrics, and tumefaction of the tracheo-bronchial glands, which it was 
claimed produced the spasmodic cough by compressing the recurrent 
laryngeal nerve. 

Pathological Anatomy. — Catarrhal inflammation of the air-passages 
is uniformly present. It occasionally occurs on the mucous surface of the 
nostrils and pharynx, but is often absent from these parts. In the major- 
ity of cases the inflammation affects the surface of the glottis and that 
below the glottis. However, in not a few cases the surface of the larynx 
and trachea is pale and not swollen, or the inflammatory appearance is 
limited to a small part, as the ventricles of the larynx, while the mucous 
coat of the bronchi and their branches is swollen and red, and covered 
with tenacious mucus. Sometimes certain alveoli are found distended by 
a thick muco-pus, producing an appearance like minute tubercles. 

A common lesion found in the lungs of those who have perished with 
this malady is emphysema, affecting chiefly the peripheral portions of 
the upper lobes. It is commonly vesicular emphysema occurring from 
over-distension of the air-cells, but in some instances the air has escaped 
into the connective tissue, causing interstitial emphysema. According to 
my recollection of fatal cases, which have occurred from time to time in the 
institutions of New York, and in which I have made post-mortem exam- 
inations, the upper lobes were exsanguine and inflated to nearly the fullest 
extent possible within the thorax, while other portions of the lungs pre- 
sented areas of pneumonic, or more or less complete atelectatic solidifica- 
tion. Pneumonia, atelectasis, and small extravasations of blood in the 
lungs, are, indeed, common lesions. Hyperplasia of the bronchial glands 
is also common, and hyperplasia has also been occasionally observed of 
other lymphatic glands, as the mesenteric. An ulcer under the tongue 
which observers have frequently noticed is now attributed to pressure of 
the tongue on the lower incisors during the cough. 

In fatal cases, small extravasations of blood in or upon the brain are 
common, as is also passive congestion of the sinuses, veins, and capilla- 
ries, meningeal and cerebral, attended with more or less transudation of 
serum within the ventricles of the brain, and between the meninges. Large 
dark and soft clots, and occasionally some that are white or yellow, are com- 
mon in the intra-cranial sinuses, especially if, as often happens, death have 



298 PERTUSSIS. 

occurred in convulsions, which supervened upon the severe spasmodic 
cough. 

Symptoms. — Pertussis consists of three stages : first, that of catarrh of 
the air-passages ; secondly, the stage of spasmodic cough, or for brevity 
the spasmodic stage ; thirdly, the stage of decline. 

The first period is characterized by the symptoms of coryza and bron- 
chitis, which present nothing peculiar or different from ordinary catarrh 
of the same parts, unless occasionally the cough be more frequent and 
teasing. Trousseau has known it to be repeated forty or fifty times per 
minute. The eyes present a moderately suffused appearance, and there is 
sneezing, with defluxion from the nostrils, but less than in the commence- 
ment of measles. The cough, which commences as soon as the catarrh 
affects the larynx, is accompanied by little or no expectoration. The pulse 
and respiration are moderately accelerated, and such other symptoms as 
commonly accompany catarrh of a mild grade are present, namely, in- 
creased heat of surface, thirst, and impaired appetite. 

The duration of the first stage varies in different cases. In severe 
hooping-cough it may last only two or three days, and in mild cases, be 
protracted to five or six weeks. It may be absent especially in very young 
infants. We have alluded above to the new-born infant, in whom there 
was no first stage, a glottic spasm occurring soon after birth. The first 
stage commonly ends in from eight to fifteen days. In fifty-five cases ob- 
served by Dr. West its average duration was twelve days and seven tenths 
of a day. It is stated above that the first stage in rare instances continues 
during the entire course of pertussis ; at least no spasmodic cough occurs. 
In two such cases which I now recall to mind, both girls, the inflammatory 
symptoms abated somewhat after the first few days, and there remained an 
occasional easy cough like that of simple bronchitis, which continued 
during a period corresponding with the ordinary duration of pertussis. The 
diagnosis would have been doubtful, except for the occurrence of pertussis, 
with its regular stages, in other children of the same families. 

Second Period. — This may commence quite abruptly, but ordinarily its 
beginning is gradual. While the cough commonly has the character pres- 
ent in the first stage, it is now and then observed to be more severe and 
spasmodic, especially at night, and when the patient is in any way excited. 
The spasmodic element increases, so that in the course of a week all doubt 
as to the nature of the disease is removed. 

The severity of the cough in the second stage varies considerably in 
different cases. It sometimes commences quite abruptly, with little warn- 
ing, but commonly there is premonition of it, and the child endeavors to 
repress it. He experiences a tickling sensation in the throat, or median 
line of the chest, or a feeling of constriction. He leaves his playthings, 
and rests his head on his mother's lap, or takes hold of some firm object 
for support ; his face has a grave or even anxious appearance, while the 



SYMPTOMS. 299 

pulse and respiration are somewhat accelerated. Immediately the cough 
begins. It consists in a series of short and hurried expirations, which 
expel a large part of the air contained in the lungs, followed by a hurried 
inspiration, which is difficult and noisy on account of the spasmodic con- 
traction of the laryngeal muscles, and narrowing of the glottic aperture. 
The sound which accompanies the inspiration, and which is often absent, 
especially in infants, is designated the hoop. The forcible expirations, 
and difficulty experienced in expelling the air from the lungs on account 
of the constriction of the glottis, afford explanation of the emphysematous 
distension of the air-cells in the upper lobes, which we have seen is so 
common in severe pertussis. 

There may be a single series of expirations terminating in the man- 
ner stated, but often there are several such series embraced in a paroxysm. 
The cough commonly ends in the expulsion of frothy mucus from the 
bronchial tubes, and sometimes in vomiting. During the cough there is 
temporary arrest of blood in the lungs, leading to congestion in the right 
cavities of the heart, and throughout the systemic circulation ; therefore 
the face is flushed and swollen, and occasionally haemorrhage occurs under 
the conjunctiva, or from one of the mucous surfaces. The most frequent 
haemorrhage is epistaxis. When the cough ceases, and normal respiration 
is restored, the fulness of the vessels immediately abates ; but often puffi- 
ness of the features is observed, due to serous infiltration of the subcuta- 
neous connective tissue, and continuing for days or weeks during the 
period when the cough is most severe. The paroxysm lasts from a quarter 
to a half or even a whole minute, and in that time, in cases of ordinary 
severity, there are often as many as fifteen or twenty series of expirations. 

At the close of the paroxysm, if there be no complication, the symptoms 
soon abate ; the temperature, pulse, and respiration become normal, and 
there is no evidence of disease. The cough in the second stage is much 
more frequent in one case than another. At the height of this stage it is 
generally more severe if it occur at long intervals than when frequent. 
During the weeks in which pertussis is most severe, there is, in the average, 
about one paroxysm of coughing in each hour. 

The cough increases in severity till the third week of the second stage, 
or the thirtieth to thirty-fifth day of the disease, after which it remains 
stationary for a certain time. It is apt to be more frequent in the night 
than daytime. Sometimes it occurs while the child is quiet ; it may even 
awaken him from sleep, but it is often also produced by mental excitement 
or by physical exertion. Anger or fright gives rise to it, and therefore the 
child is apt to cough when being examined by the physician, or when his 
wishes are not complied with. The ordinary duration of the second stage 
is from thirty to sixty days. It may, however, be considerably longer or 
shorter than this. 

The third stage, which commences at the time when the spasmodic 



300 . PERTUSSIS. 

cough begins to abate, is short, not continuing longer than two or three 
weeks. A protracted stage of decline indicates some complication. 
While the sputum in the second stage is mucous and frothy, that in the 
third stage is more opaque and puriform. 

In the third as in the second stage, if there be no complication, the pulse 
and respiration in the intervals of the paroxysms are nearly or quite nat- 
ural. Febrile excitement may, however, now and then occur from trifling 
causes, or, indeed, without any apparent cause. The digestion and the 
general health in uncomplicated pertussis remain unimpaired, with the 
exception of more or less emaciation, which is apt to occur in all but the 
mildest cases, in consequence of the frequent vomiting. After complete 
recovery, it is not unusual for the spasmodic cough to reappear, at times, 
for one or even two years. The cough of ordinary simple laryngitis, or 
bronchitis, assumes this character. 

Complications. — These, like the symptoms, are chiefly of a twofold 
character, namely, inflammatory and neuropathic. From the nature of 
the cough in pertussis, it would naturally be supposed that that spasmodic 
affection, which is now designated internal convulsions, and which is char- 
acterized by spasm of certain muscles of respiration, would be a frequent 
complication. It does sometimes occur in young children, but it is not 
common. Clonic convulsions affecting the external muscles are, on the 
other hand, not infrequent. They occur chiefly in the second stage, when 
the cough is most severe, and in infancy much more frequently than in 
childhood. They are apt to be general and severe, or if not of this char- 
acter at first, to become such. The convulsions commence, in most in- 
stances, in or directly after the paroxysm of coughing ; but they some- 
times occur in the interval when the child is quiet. 

Rilliet and Barthez remark : " Almost all infants succumb to this com- 
plication, ordinarily in the twenty-four hours which follow the first, 
attack ; nevertheless, life may be prolonged during two or three days. ' ' 
(Article Coqueluche.) In my own practice this complication usually ended 
fatally before bromide of potassium and chloral were employed, but with 
the proper use of these agents it can often be arrested. In the month of 
June, 1867, I was attending a little girl two years and four months old, 
who had reached the fifth week of pertussis, when she was seized with 
general clonic convulsions. The mother, who was requested to keep a 
record of the number of convulsions, stated that there were twenty in all, 
occurring within forty-eight hours. They affected both sides, the 
shortest lasting only three or four minutes, the longest seventy-five min- 
utes. The treatment in this case, which eventuated favorably, will be 
noticed hereafter. 

In those who die of convulsions occurring in hooping-cough, the most 
constant lesion is congestion of the cerebral veins and sinuses, often with 
transudation of serum. This congestion is due in part to the cough which 



COMPLICATIONS. 301 

precedes the convulsions and in part to the convulsions themselves. At 
the autopsies which I have made of two infants, who died in hospital 
practice from hooping-cough, accompanied by convulsions, all the cerebral 
sinuses were filled with clots, which were generally soft and dark ; but in 
the lateral sinuses clots were found which were light-colored. The light 
color of a clot, either in a vein or sinus, indicates its ante-mortem formation. 

The gravity of the convulsive attack can be ascertained by observing 
whether the patient readily recovers consciousness. Its return indicates 
that there is no serious congestion. On the other hand, great drowsiness 
remaining, or a semi-comatose state, indicates persistent congestion, and, 
perhaps, even the formation of clots in the sinuses of the brain. Death 
from convulsions is usually preceded by coma. Occasionally meningeal 
apoplexy supervenes upon the congestion, and death is immediate. 

The most frequent inflammatory complications are bronchitis and pneu- 
monitis. Inflammation of the bronchial tubes of a mild grade, we have 
seen, is a common accompaniment of pertussis, but when it extends to the 
minuter tubes, or becomes so severe as to cause acceleration of respira- 
tion, it is, properly, a complication. Both bronchitis and pneumonitis, 
occurring as complications, are developed, with few exceptions, in the 
second stage. Bronchitis is accompanied by accelerated respiration and 
pulse, and increased temperature. The danger is proportionate to the 
amount of dyspnoea. 

Pneumonitis is a less common complication than bronchitis, but it 
occurs more frequently in pertussis than in any other constitutional 
malady of early life, excepting measles. The congestion, which results and 
remains in the lung when the cough is frequent and severe, favors the 
development of pneumonia. The symptoms and physical signs which ac- 
company this inflammation and serve for its diagnosis are the same as 
in the primary form of the disease, and are described elsewhere. Bron- 
chitis or pneumonia usually moderates the severity of the spasmodic 
cough, for when the inflammatory element in pertussis increases, the 
spasmodic abates. On the abatement of the inflammation, however, the 
cough usually regains its former convulsive character. The fact may be 
stated in this connection, that any complication or intercurrent disease, 
which is attended by decided febrile reaction, ordinarily renders the 
cough for the time less spasmodic. 

The occurrence of bronchitis or pneumonia is shown by the elevated 
temperature, acceleration of pulse and respiration, short and frequent 
cough. These symptoms do not cease so long as the inflammation con- 
tinues, whereas in uncomplicated pertussis the patient seems nearly or 
quite well between the coughs. In pneumonia the respiration is accom- 
panied by the expiratory moan, and in both bronchitis and pneumonia 
there is more or less depression of the infra-mammary region during in- 
spiration. These symptoms, in connection with the physical signs, render 



302 PERTUSSIS. 

diagnosis in most instances easy. Although the general character of the- 
cough is changed, a cough now and then occurs, even when the inflamma- 
tion is pretty severe, sufficiently spasmodic to indicate the nature of the 
primary affection. Capillary bronchitis and pneumonia are always serious 
complications. 

Not only is more or less emphysema a common complication of severe 
pertussis, but bronchiectasis also occurs in certain cases, due to the same 
conditions. Emphysema is a common lesion in young and feeble infants, 
even when there is no history of any previous severe disease of the respi- 
ratory organs. I have found it one of the most common lesions in infants 
of feeble constitutions, who die in the hospitals and asylums of New York, 
but it is apt to be interstitial and confined to a small part of the upper 
lobes. It is not accompanied by that general distension of the alveoli 
and consequent enlargement of the lobes, which occur in the emphysema 
of pertussis. Its chief cause in these feeble and wasted infants appears to 
be impaired nutrition and change in the molecular condition of the pul- 
monary tissue. The same condition often occurs in severe and protracted 
pertussis, and therefore serves as an additional and efficient cause of the 
emphysema. 

The following was a not unusual case of this disease as it occurs in> 
the tenement houses and asylums of New York. At the meeting of the 
New York Pathological Society, October 14, 1868, I exhibited em- 
physematous lungs, removed from an infant who died at the age of nine- 
teen months, at the commencement of the fourth week of pertussis. 
Death occurred from thrombosis in the lateral sinuses of the cranium, re- 
sulting from the severe spasmodic cough, eclampsia, and feebleness of the 
circulation, as the infant was previously in a reduced state from chronic 
entero-colitis. At the autopsy the superior lobes of both lungs were found 
exsanguine, doughy to the feel, and enlarged so as to rise above the level 1 
of the other lobes. The resiliency and elasticity of the lung tissue in 
these lobes were evidently greatly impaired, and their air-cells in a state 
of over- distension. The other lobes were healthy, except that one of them 
was the seat of catarrhal pneumonia. In this case there had been no- 
disease affecting the respiratory apparatus previously to the pertussis, so 
that the incipient vesicular emphysema was referable to the severe cough 
and impaired nutrition of the lungs. 

Occasionally we meet cases of severe pertussis in which, while there is 
over-distension of the alveoli of the upper lobes, collapse occurs over a 
greater or less extent of the lower lobes. Collapse, like emphysema, may 
continue for weeks or months subsequently to pertussis, and then gradu- 
ally disappear, but in the following rare case in my experience it was 
permanent. John O'Neil, aged 5^- years, was brought to the Bureau for 
the Relief of the Out-door Poor in New York, in December, 18*76. He 
lived in the underground basement of a tenement house, and was supported 



COMPLICATIONS. 



303 



Fig. 14. 



by charity, except, at intervals, when his father, who was dissipated, 
could obtain work. At the age of fifteen months he had a glandular 
swelling on the right side of the neck, which suppurated, and three months 
later one on the opposite side, which also suppurated. At the age of 2-j- 
years he had bronchitis, the cough of which did not abate till two months 
subsequently. When near the age of three years he had measles, and the 
cough from this disease lasted three or four months. In the summer of 
1875, or about one year subsequently to the measles, he contracted per- 
tussis, which was severe, but was allowed to run its course without treat- 
ment. It lasted four months, never, however, confining him to bed or 
materially impairing his appetite. One morning about the close of the 
second month of the malady, the parents first 
observed depression of the right side of the thorax. 
This gradually increased for a few weeks and has 
been permanent. The parents stated that he had 
never been confined to the house or without ap- 
petite except during the week of measles. 

Since his recovery from pertussis he has had 
his usual appetite and general health, but crying 
or excitement commonly brings on a pretty 
severe cough. The depression of the thorax 
examined in front, begins quite abruptly in the 
line of the left costo-chondral articulations. Cir- 
cumferential measurement of the left side from 
the middle of the sternum to the spine, the tape 
lying a little below the nipple, gives eleven and 
a half inches, while corresponding measurement 
of the right side gives seven and a half inches ; 
pulse 136, sounds of the heart normal ; respira- 
tion 44. On auscultation over the right side of 
the chest we observed bronchial respiration, and 
a feeble bronchophony, with perhaps slight vocal 

fremitus. The accompanying figure is from a photograph by Mr. Mason, 
photographer to Bellevue Hospital. My first impression on observing this 
case was that it was one of unexpanded lung, which had been compressed by 
a pleuritic effusion, but it is seen that the history points clearly to pertus- 
sis as the cause of the deformity. The depression occurred somewhat 
suddenly when the cough was most severe, and when there was no fever, 
loss of appetite, or other symptoms of pleuritis. The patient had not 
presented any marked evidence of rachitis, but was decidedly strumous. 

Pertussis is sometimes complicated by the eruptive fevers. There does 
indeed seem to be some affinity between it and measles, so that many 
epidemics of the two have been observed at about the same time. Dur- 
ing my term of service in the New York Foundling Asylum, in May, 1878, 




30-i PEETUSSIS. 

measles and pertussis prevailed in the wards at the same time. Eighteen 
of the children, who were having pertussis, contracted measles, and the 
Sisters, who were very intelligent and faithful observers, and were re- 
quested by me to notice the effect of the complication, stated that with 
few exceptions the severity of the hooping-cough was increased during 
the continuance of the exanthem. This is contrary to the general belief 
of the effects of inter-current febrile diseases. 

Diagnosis. — During the period of invasion it is impossible to diagnos- 
ticate pertussis. Its nature can only be conjectured from a known ex- 
posure or from the epidemic occurrence of the disease. In the second 
stage, which is characterized by the spasmodic cough, diagnosis is ordi- 
narily easy, and often the parents are able to announce the nature of the 
disease when the physician is called. Still, a mistake is sometimes made ; 
a spasmodic cough very similar to that of pertussis occasionally occurs in 
other maladies. Young infants with bronchitis frequently experience 
great difficulty in the expectoration of mucus, which collects in the air- 
passages and provokes a suffocative cough. The following facts will aid 
in making the diagnosis. Bronchitis, accompanied by a suffocative cough, 
is an acute disease, and the cough occurs at an early period, usually in the 
first week. It lacks the inspiratory sound or the hoop, and is associated 
with constantly accelerated respiration and well-marked febrile symptoms, 
dependent on the inflammation. Moreover, the cough is only occasionally 
suffocative, according to the amount of mucus in the tubes. The spas- 
modic cough of pertussis, on the other hand, is preceded by the stage 
of invasion, and it occurs only in the second stage, when the febrile 
symptoms have abated. Again, the suffocative cough of bronchitis rarely 
ends in vomiting, which has been seen to be so common in the cough of 
pertussis. 

The only other disease with which there is much likelihood of con- 
founding pertussis is bronchial phthisis. The points of differential diag- 
nosis are the following : the one epidemic, and spreading by contagion ; 
the other non-contagious and isolated : the one embraced in three distinct 
stages, and much shorter ; the other chronic, and presenting no stages, but 
commencing with mild non-febrile symptoms, and progressively becoming 
more severe : in the one an absence of symptoms in the intervals of the 
cough, provided there be no complication; in the other constant symptoms, 
such as are common in tubercular disease. The previous health, and the 
presence or absence of a tubercular cachexia, should be considered in de- 
termining the nature of the disease, and usually, in bronchial phthisis, the 
lungs are also affected, so that auscultation and percussion may furnish 
positive proofs of the nature of the cough. 

The attacks of suffocative cough, which are produced by the lodgment 
of a foreign body in the larynx, or lower down in the air-passages, bear a 
close resemblance to those of pertussis. The diagnosis can be made by 



PROGNOSIS. 305 

the history, for in the one case there is a preliminary catarrhal stage, and 
in the other the cough begins abruptly, and usually after the known swal- 
lowing of the offending substance, which produces dyspnoea and a spas- 
modic cough as soon as it enters the larynx. The presence of the body 
can also be determined in a large proportion of cases by the larnygoscope 
and auscultation. 

Prognosis. — A larger proportion doubtless recover under the better 
therapeutics of the present time than in former years. According to 
Hirsch (II., p. 105) 72,000 persons perished from this disease in England 
and Wales between 1848 and 1855, or one in every forty who died ; and 
Wilde's reports show that it stands fifth as regards mortality among the 
epidemic diseases of Ireland. In New York City during the half century 
ending with 1853, 4,840 died of pertussis, or one died from this disease 
in every *76 of deaths from all causes. 

As a rule, the older the child the better the prognosis. Young infants 
may die of suffocation due to the glottic spasm. Eclampsia with extreme 
passive congestion of the encephalon is a not infrequent complication in 
children under the age of five years, and it is apt to terminate fatally. 
It may, however, in my opinion, be averted in most cases by proper 
treatment. In rare instances death may occur in or immediately after a 
paroxysm of coughing, in consequence of the rupture of cerebral or men- 
ingeal capillaries, and the effusion of blood, or from stasis and coagulation 
of blood in the venous system, especially if convulsions have supervened 
upon frequent and protracted paroxysms of coughing. Other complica- 
tions, which are likely to arise under conditions which favor their devel- 
opment, and which greatly increase the danger and render the prognosis 
unfavorable, are capillary bronchitis, pneumonia, diphtheria, and in the 
summer season intestinal catarrh. In New York I have noticed that 
pertussis occurring in the summer is much more fatal if it become com- 
plicated with the intestinal catarrh which is an epidemic among infants 
during that season. 

Feebleness of system and antecedent and accompanying chronic dis- 
ease increase the danger. Pertussis sometimes produces so much emacia- 
tion and loss of strength, in consequence of the severity and frequency 
of the cough, and the repeated vomiting, that intercurrent diseases which 
in favorable states of the system would probably end in recovery, are very 
apt to prove fatal. 

I usually inform the family that the patient is doing well, if he seem 
entirely well between the paroxysms ; but if he appear ill, whether with 
somnolence, fretfulness, fever, loss of appetite, accelerated breathing, or 
diarrhoea, he is not doing well, and probably has some complication, which 
requires immediate attention. Sudden deaths occur in the second stage ; 
but deaths from causes and conditions which operate in a gradual and 
protracted manner, may occur in the second or third stage. 
20 



306 PERTUSSIS. 

Treatment. — In the catarrhal stage the treatment should be the same- 
as in mild idiopathic catarrh. Demulcent and gentle expectorant meas- 
ures are required. Care should be taken to employ nothing which re- 
duces the strength or impairs the general health. If there be much 
bronchitis with accelerated breathing and frequent cough, mild counter- 
irritation to the chest, and the use of the oil-silk jacket are proper. 

Therapeutic measures are chiefly indicated in the second stage, or that 
of convulsive cough. Proper treatment may control the severity of the 
cough, and abridge the duration of the second stage, and prevent or con- 
trol complications. As with most other diseases whose cause and nature 
are obscure, and which under ordinary circumstances terminate favorably, 
pertussis has received a great variety of treatment. The enumeration of 
the medicines and modes of treatment which have had their season of 
repute, and been employed by intelligent physicians, would occupy too 
much time. The treatment should vary in some respects according to the 
case, but a small number of medicines suffices, even in the most severe 
and obstinate forms of the malady. Those which I have found most use- 
ful for internal treatment, and which are employed more than any others 
in the institutions of New York, are belladonna, quinine, the bromides, 
and hydrate of chloral. They are now largely used in the treatment of 
pertussis in this city, and I can bear witness that a larger number of cases 
treated by them escape complications and recover, than under other modes 
of treatment which were formerly employed. 

When the second stage commences, belladonna should be given in ordi- 
nary cases in morning and evening doses. Children require a larger pro- 
portionate dose than adults, and it can with few exceptions be safely ad- 
ministered even to the youngest infant in a quantity gradually increased 
till the cough is moderated or physiological effects are produced. The 
physiological effects are more readily produced in some than in others. 
Thus recently I gradually increased the doses of the tincture of belladonna 
to twelve drops for a child aged three and a half years, who had severe 
pertussis, without producing the characteristic efflorescence, while smaller 
doses from the same bottle produced this effect in older children. Prob- 
ably the action of the drug is on the respiratory centres in the medulla, and 
not directly on the muscles, as once held. Rarely I have discontinued the 
belladonna on account of diminished flow of urine, which this agent may 
or may not have produced, and very rarely on account of suddenly 
developed muscular weakness, which I had reason to think the belladonna 
caused. This occurred in the case alluded to above, in which twelve 
drops of the tincture were given, so that the muscles seemed flabby, and 
the trunk and head were supported with difficulty. 

Trousseau sometimes employed atropia in place of belladonna, since 
the medicinal property of the plant resides in this alkaloid, which beingp 
crystalline has uniform strength. He gave the neutral sulphate of atropia 



TREATMENT. 307 

Y^j part of a grain, dissolved in distilled water, to in- 
fants or young children. He gave the medicine twice each day, and for 
older children ordered a proportionately larger dose. Brown-Sequard, in 
remarks made before the United States Medical Association in May, 1866, 
maintained that the duration of pertussis, so far as its nervous ele- 
ment is concerned, might be abridged to a few days by doses of atropia 
sufficiently large to produce toxical effects. He recommended a dose which 
will cause, and repeated will maintain, delirium for three days, after which 
he stated that the cough is no longer spasmodic. But a more moderate 
dose, even with a longer time to effect a cure, seems preferable. The 
tincture of belladonna is most convenient for use, and most of that kept 
in the shops is active and reliable. The doses which I have ordinarily 
found to be sufficient, and which also produced efflorescence, were as fol- 
lows : to a child of two years three drops, and to one of six or eight years, 
eight or ten drops, morning and evening. I always, however, commence 
with a smaller number, and continue to administer the dose which produces 
the local effects alluded to, unless the cough be moderated with smaller 
doses. In the majority of cases I have noticed no decided effect till the 
rash was produced, when the symptoms improved, the cough becoming 
less frequent or less severe. By the belladonna treatment the spasmodic 
stage may not only be rendered mild, but abridged to two or three weeks. 
In some cases the severe cough begins to yield almost immediately under 
full doses of this agent, but in other cases its continuance for some days 
is necessary, with other remedies as adjuvants, before there is any appre- 
ciable benefit from its use. 

The use of quinine as a remedy for pertussis was first strongly recom- 
mended by Binz, who embraced the theory of Letzerich, that this disease 
is produced by a fungus, upon which the quinine acts injuriously. I have 
not observed that improvement from the use of this agent, when employed 
alone — and it has been largely prescribed in the institutions of New 
York — which I have observed in cases treated at the same time with 
morning and evening doses of belladonna. Its good effects upon the spas- 
modic cough are probably due to the fact that it diminishes reflex irrita- 
bility (Schlakow and Eulenberg). At the same time it acts as a tonic, 
and improves the appetite, and tends to prevent any depressing effect 
which might occur from the belladonna. It is beyond question the proper 
remedy in those frequent cases in which febrile symptoms arise, whether 
from some complication as bronchitis, pneumonia, or other causes, in 
ordinary cases a child of five years should take about two grains four times 
daily, in the elixir adjuvans or other convenient vehicle. As an anti- 
pyretic a larger dose may sometimes be needed. 

As the paroxysms are apt to be more severe at night, and the patient 
consequently be deprived of the required sleep, a medicine is indicated 
which will procure some hours of rest, and thereby diminish the number 



308 P E K T U S S 1 S . 

of paroxysms. For this purpose the hydrate of chloral is especially useful 
given in doses of two to five grains, according to the age, and perhaps re- 
peated. It does not seem to me that chloral exerts any marked influence 
upon the cough ; it seems to be useful chiefly in the manner stated, 
namely, by procuring prolonged sleep. 

One of the chief dangers from pertussis we have seen to be the occur- 
rence of great passive congestion of organs, especially of the brain, with 
the liability to hemorrhages, serous effusion, and eclampsia. This is in 
great part prevented by the action of the medicines mentioned above, 
which diminish the severity of the cough, or its frequency. But when 
there are great and frequent congestions of the nervous centres, producing 
eclampsia or premonitions of eclampsia, the use of one of the bromine 
compounds is indicated for its prompt and decided action in averting the 
danger. Even if the symptoms be not urgent, its tranquillizing effect, and 
•especially its prompt action in diminishing reflex irritability, render it 
one of the most useful agents in pertussis. If there be sudden twitching of 
the muscles, marked stupor, headache, or fretfulness, or adduction of the 
thumbs across the palms of the hands during the cough, I never fail to 
give the bromide of potassium in sufficiently large and frequent doses, and 
now eclampsia occurs much more rarely in a case which I treat from the 
commencement, than in former years. 

Although the treatment described above renders pertussis more man- 
ageable and less fatal than formerly, we have during the last three years 
achieved still greater success by the use of the steam atomizer. This 
instrument was first used for the treatment of pertussis during a severe 
epidemic, in the New York Foundling Asylum, and the result was so 
satisfactory, that it has been uniformly employed since in this institution, 
during the epidemics, to the almost total exclusion of other remedies. 
With this treatment very few complications have occurred, such as 
eclampsia or pulmonary inflammation, and the spasmodic cough 
has been almost uniformly so modified that the usual remedies did 
not seem to be required, and what often promised in the beginning to be 
a severe attack became mild. The same success has attended the treat- 
ment of cases in my private practice. The steam atomizer is used from 
three to five minutes every six hours, and in severe cases oftener, and it is 
the uniform opinion of the resident physician, the sisters, and nurses of 
the asylum, that no other treatment is required for uncomplicated pertus- 
sis. The medicine used in the atomizer has been the following ; 

IJ. Acid, carbolic, 3 ss ; 

Potas. chlorat., / __ 7 ., . 
' v aa 3 ij ; 
Potas. bromidi, ) 

Glycerinae, 1 ij ; 

Aquae, § vj. Misce. 

From the experience therefore of two years, I give the preference to 



PROPHYLAXIS. 309 

inhalations over all other modes of treatment. The good result from 
their use i3 probably due to the anaesthetic effect, particularly of the car- 
bolic acid, on the terminal filaments of the sensitive nerves in the laryn- 
geal surface. 

The complications of pertussis require prompt treatment. Whenever 
the child feels ill between the paroxysms, he should be carefully examined, 
and some complication will probably be found which requires treatment. 
If the bronchitis have increased so as to become a complication, or pneu- 
monia have arisen, the whole chest should be covered with a light flax- 
seed poultice containing one-sixteenth part of mustard, while quinine and 
ammonia with alcoholic stimulants are given at regular intervals. Cere- 
bral accidents are best arrested by the warm foot-bath, cold to the head, 
and by the bromide and chloral. 

Diphtheria not infrequently supervenes as a complication in a locality 
where it is endemic or epidemic, and if mild is apt to be overlooked. Re- 
cently I have seen a case in which diphtheria complicating pertussis had 
continued four days, without being recognized by the attending physician, 
the symptoms being attributed to other causes. The diphtheritic patch 
in these cases is apt to appear upon the well-known sore under the tongue, 
in addition to its occurrence upon other parts. This secondary form of 
diphtheria requires the same treatment as the primary form. 

Hauke, in 1862, published experiments which showed that both car- 
bonic acid and ammoniacal vapors when inhaled increase the cough, 
while the inhalation of oxygen produced no cough and was agreeable to 
the patient. Hence children in close and crowded apartments suffer most 
severely from pertussis, and those who are taken to parks, or the country . 
where vegetation absorbs the carbonic acid, not only obtain benefit from 
the general invigorating influence, but also as regards the cough. The 
fact that fresh and pure air benefits the cough has indeed long been 
known, and has influenced practice, for patients are almost universally 
allowed to be much of the time in the open air, and are taken to the parks 
and upon excursions. Nevertheless caution in this regard is required, for 
exposure in wet weather or to sudden changes of temperature is very apt 
to develop bronchitis or pneumonia. 

Prophylaxis. — Pertussis is very contagious, and it appears to be, in 
nearly all instances, if not in all, contracted by inhaling the breath of the 
patient. I have never observed a case in which it seemed to be communi- 
cated through a third person, and it is not, I think, usually contracted 
by children living in the same house, if there be no personal contact. 
There is not, therefore, that urgent need of disinfection, and of caution 
on the part of physician and nurse in their subsequent intercourse with 
healthy children, as in case of the eruptive fevers. 



310 PAROTIDITIS. 



CHAPTER II. 

PAROTIDITIS. 

Ordinarily, parotiditis, or parotitis, or mumps, has no premonitory 
stage ; but in exceptional cases languor with fever precedes the disease for 
a few hours. Mumps commences with tenderness in the parotid region, 
followed soon after by tumefaction. The swelling gradually increases ; it 
fills the depression under the ear, extends forward and upward upon the 
cheek, and downward to a greater or less extent upon the neck. It has 
been demonstrated in case of symptomatic parotiditis, and the same is 
probably true of the idiopathic disease, or mumps (Virchow), that the 
swelling is due to inflammation of the gland-ducts and consequent oedema 
of the interstitial tissue. The inflammation is specific, due to a materies 
morbi in the blood, and hence its decline after a fixed period. It reaches 
its maximum from the third to the sixth day. The most prominent point 
at this time is immediately underneath the lobule of the ear. The tumor, 
which is firm but slightly elastic, presses outward the lobule. In most 
cases the skin preserves its normal appearance over the swelling, but oc- 
casionally it presents a faint blush. The pressure which movements of 
the jaw produce on the gland renders mastication and even talking pain- 
ful. Febrile movement more or less intense occurs, lasting, in ordinary 
cases, not more than forty-eight hours, but occasionally it is more pro- 
tracted. Vomiting and epistaxis are sometimes present. The swelling 
having attained its maximum size, remains stationary a short time, when 
it begins to decline, and by the sixth to tenth day it has entirely subsided. 

In most cases parotiditis is double ; it commences on one side, more 
frequently the left than right, and in from one to four days the opposite 
gland is involved. In those exceptional cases in which only one parotid 
is affected, the opposite gland may be the seat of the disease at some sub- 
sequent period. It has been estimated that the proportion of unilateral 
to double mumps is as one to ten. 

The total duration of parotiditis is usually from eight to ten days ; in 
the mildest cases it may not be more than five days. The submaxillary 
•glands are often involved in connection with the parotids, and sometimes 
also the sublingual, although, from their small size and concealed position, 
their tumefaction escapes notice. Rarely the tonsils are also tumefied. 
Sometimes free perspiration occurs at the commencement of convalescence. 

The swelling of the parotids sometimes abates suddenly, and in the 
male the testicle, epididymis, and tunica vaginalis become inflamed ; 
while in the female the mammary glands, ovaries, or the labia majora, 



TREATMENT. 311 

are the seat of the so-called metastasis. Occasionally these inflammations, 
which are less frequent in young children than those near the age of 
puberty, when the sexual organs are becoming more developed, occur 
without subsidence of the parotid swelling. They cause considerable 
increase in the fever and constitutional disturbance, but with proper 
treatment decline in six to eight days, pursuing the same course as the 
parotid inflammation. 

Nature. — Parotiditis is contagious. It is rare in infancy and after 
the middle period of life, occurring chiefly in childhood, youth, and early 
manhood. An incubative period of about twelve days was ascertained 
by me in cases under observation in the Protestant Episcopal Orphan 
Asylum of this city. The observations of others give a similar result. 
Parotiditis is a blood disease, having the local manifestation described 
above, and which is our only means of diagnosis. 

Diagnosis. — If the physician have seen but few cases of mumps there is 
danger that he may mistake the swelling for an inflamed cervical gland, 
or vice versa, but an inflamed cervical gland presents to the finger a hard- 
ness almost like that of cartilage, and it is circumscribed or round, and 
does not invest the ear. These characteristics contrast with the elasticity, 
seat, and shape of the parotid swelling, which extends forward on the 
cheek and surrounds and elevates the lobule of the ear. Tumefaction 
resulting from diphtheritic or any other form of faucial inflammation, or 
from periostitis affecting the root of the posterior molar, may be detected 
by examining the fauces and interior of the mouth. 

Treatment. — This is very simple. Oakum or carded wool may be 
bound over the swelling, and the surface occasionally rubbed with sweet 
oil. Mild laxative and diaphoretic drinks, such as bitartrate of potassium 
or lemonade, are useful. If metastasis occur, the new local affection should 
receive chief attention. It should be treated in the same manner as if it 
occurred independently of the mumps, while emollient poultices or fomen- 
tations should be applied over the parotids. The ill effects of repellant 
applications in mumps are shown by the following case : 

On March 19, 1877, I was requested to see a young gentleman of eigh- 
teen years. He had been well till March 14th, when he complained of 
pain below his ears, and his mother applied a towel, wrung out of cold 
water, around his neck. On the following day slight swelling was observed 
under the angle of the lower jaw, on the right side (submaxillary gland), 
and the cold application was continued. On the 17th the swelling had 
disappeared, but the fever and headache had greatly increased, so that he 
was compelled to lie in bed. On the 19th, at my first visit, he had such 
violent headache, and was so intolerant of light and noise, that I greatly 
feared that he had acute encephalitis. All swelling under the ears was 
gone ; the left testicle was tender, and beginning to swell ; axillary tem- 
perature 102°. The cold cloths were removed from the neck and applied 



312 PAROTIDITIS. 

to the head, and potass, bromid., gr. xxv, administered every third hour. 
20th. Axillary temperature 104° ; symptoms unabated and alarming. 
Ordered six leeches to be applied upon the temples and left groin, and a 
purgative, and two drops of the tincture of aconite to be given with each 
dose of the bromide. 21st. Temperature 103°. States that numbness 
and a pricking sensation which he had felt in both legs during the last 
forty-eight hours had ceased (possibly from the aconite). 23c?. Is conva- 
lescent. Has no return of the swelling under the ears, and the orchitis- 
has abated. 



SECTION IV. 

OTHER GENERAL DISEASES. 



CHAPTER I. 

INTERMITTENT FEVER. 

This is a constitutional malady produced by a miasm which emanates 
from the soil. I have notes of 36 cases of this disease occurring under the 
age of 3-^- years. Several of these patients were treated in private practice, 
and the rest in the institutions with which I have been connected. In chil- 
dren above the age of 34- years intermittent fever differs but little from that 
of the adult, while in those under this age it presents certain peculiarities. 
Of the 36 cases which I have observed, 19 had the quotidian form, 10 the 
tertian, 2 the tertian becoming afterward quotidian, 1 the quotidian be- 
coming afterward tertian, while in the remaining 4 cases the form of the 
disease is not stated. In quotidian ague the malaria has been supposed to 
act more powerfully on the system, or the system is more susceptible to its 
influence than in the tertian form, and hence the fact that the quotidian is 
the prevailing type of ague in tropical regions, where vegetation is luxuri- 
ant, marshes extensive, and the heat intense. According to this theory, 
the feeble resisting power in the system of the infant explains the fact that 
it has quotidian more frequently than tertian intermittent, although the 
latter is much more common in the adult in this climate. 

Facts demonstrate that infants sometimes receive intermittent fever from 
their mothers. If mothers during gestation have malarious cachexia, their 
infants, whether born at full time, or, as often happens, prematurely, are 
apt to be small, thin, and feeble, and occasionally they have soon after 
birth distinct paroxysms of the ague. Dr. Stokes related the case of a 
pregnant woman with ague, who believed that she noticed periodical tre- 
mors of her foetus, but I suspect that she was mistaken, as regards the 
cause, for the paroxysm of intermittent in young children is not ordinarily 
accompanied by tremors. 

The youngest infant in my practice who apparently derived the ao-ue 
from its mother, and probably through the foetal circulation, had the fol- 
lowing history : Its mother had occasional attacks of tertian intermittent 
during the two years preceding her confinement, and her baby when one 



314 INTERMITTENT FEVEK. 

week old was observed to have the same disease, occurring also each 
second day, the coldness and blueness in the first stage of the paroxysm 
lasting from half an hour to one hour. 

It is not fully ascertained whether a nursing infant may contract inter- 
mittent fever by lactation, but if it be admitted that it is sometimes com- 
municated to the foetus through the maternal circulation, it does not seem 
improbable that the specific principle occasionally enters the milk as well 
as other secretions. I have frequently remarked the presence of the dis- 
ease in nursing infants whose mothers were affected, and in one instance, 
an infant at the breast, whose mother had the ague, having contracted it 
in a suburban village, but was since living in a non-malarious part of the 
city, presented evident symptoms of the disease. Similar observations by 
Frank, Burdel, and others, do not indeed fully prove the communicability 
of intermittent fever by lactation, but render it highly probable. 

The period of incubation in the infant varies greatly, as in the adult. 
When the malaria is concentrated and unusually active, or the condition 
of system is favorable for its reception, the disease may commence soon 
after exposure. Thus, in tropical regions, travellers exposed for a single 
night have been known to sicken within twenty-four hours ; but in our 
-cooler latitude, a longer incubative period is the rule. In the infant, how- 
ever, in our climate, intermittent fever often begins in a very short time 
after exposure, though there may be an incubative period of some weeks. 
The following have been my observations relating to this point : A. M., 
female, 8 months old, remained two days on Long Island, in October, 
1870, and three days after her return to the city, a quotidian commenced. 
P. S., male, 11 months old, remained three days on Long Island, and a 
quotidian commenced four days after his return. K., 9 months old, re- 
mained on Staten Island one week, and eleven days after his return, a 
tertian commenced. G. K., aged 3 years, remained a day and a night on 
Staten Island in 1870 ; three weeks afterward intermittent fever com- 
menced, preceded by a week of languor. A. U., female, aged 2 years and 
2 months, had the first paroxysm of a tertian, two and a half weeks after 
returning from a visit of one week in Hoboken. As there was no malaria 
in the portions of the city where these infants resided, the incubative 
periods are nearly ascertained. 

Whatever may be the nature of the malarial poison, whether a vege- 
table cell, as Prof. Salisbury believes, or something else, it often clings 
tenaciously to the system, and is probably reproduced in it, even under 
circumstances favorable for its elimination. Thus, at one of my cliniques 
at Bellevue Hospital Medical College in 1871, a child, 10 years old, was 
presented, who had had every year for seven years attacks of intermittent 
fever. The disease was contracted at the age of three years in Harlem, 
and the subsequent residence of the family had been in a part of the city 
where there was no malaria. 



SYMPTOMS. 315 

Symptoms. — In infancy, and especially prior to the age of eighteen 
months, the symptoms differ in certain respects from those which charac- 
terize the malady in the adult, and are universally known. In childhood 
the symptoms are similar to those in the adult, and need not, therefore, 
be described in this connection. 

In the infant the type as we have seen is quotidian, with now and then 
a tertian. Advancing beyond the age of eighteen months, we meet more 
and more cases of the tertian type, and in childhood it is the common 
form. I have known the quotidian in the infant, when cured, to reappear 
a few weeks after as a tertian ; but ordinarily it remains quotidian, unless 
the patient have reached the age at which the tertian type predom- 
inates. 

The paroxysm in the young infant presents three stages, as in the adult, 
but while the second, or febrile, is well marked, the first and third are 
much less pronounced. The patient does not shake (exceptionably, one 
does even within the first year) in the first stage, but a slight tremor maj- 
or may not be observed. The countenance presents a sunken appearance ; 
the lips and fingers are livid, while portions of the surface not livid are 
pallid, with the goose-flesh appearance, which is, however, less marked 
than in children of a more advanced age. The blood leaves the sui- 
face, which consequently shrinks, while it accumulates in the veins and 
internal organs ; the pulse is feeble, and readily compressed ; the surface 
grows cool from the diminished supply of blood, but the breath is warm. 
and the internal temperature, so far from being reduced, is elevated two 
or three degrees. The parents may be alarmed at the sudden sinking of 
the vital powers, and seek medical advice, but in other instances the first 
stage is so slight that it passes unperceived till they have been taught to 
watch for it, and the second stage first attracts attention. 

In the second or febrile stage, which immediately succeeds, the pulse 
becomes full and rapid, 120 to 130 or 140 beats per minute, and the ex- 
ternal as well as internal temperature is elevated as in few other diseases 
(104°-108°). The face is flushed, surface dry, and head painful, as 
evinced by the features. This stage lasts about two or three to six or 
eight hours. The third stage, or that of perspiration, succeeds, which 
terminates the suffering of the patient till the following paroxysm. In 
infancy the perspiration is not abundant, and in the first half of this period 
is nearly absent. In the interval of the paroxysms the patient appears 
well, except a degree of languor. 

In twenty-four of the cases of infantile intermittent which I have treated 
my notes describe the character of the paroxysms. In sixteen of these 
there was no chill or trembling in the first stage, but blueness and cool- 
ness of the extremities and features, and sudden prostration. This stage 
lasted from ten minutes to one hour. In the eight remaining cases the 
infants were observed to tremble or shake as in adult cases. The perspira- 



316 INTERMITTENT FEVER. 

tion of the third stage was in nearly all cases, when observed, slight and 
of short duration, but in some it was not observed. 

During the cold stage, passive congestion of the internal organs occurs 
to a greater or less extent, but the circulation is equalized during the re- 
action of the second stage. The spleen, whose capsule is distensible, soon 
enlarges in many patients, in consequence of the frequent and great con- 
gestions, constituting the " ague cake." This enlargement is more com- 
mon in children than adults. Since my attention has been particularly 
directed to this subject, I have been able to feel the enlarged spleen, by 
examination through the abdominal walls, in probably one-third of the 
cases under the age of ten years. This organ returns to the normal size 
after the ague is cured. From the intimate relation of the spleen to the 
composition of the blood, it is evident that the character of this fluid must 
be affected if intermittent fever be protracted. The blood becomes more 
and more impoverished, and a state of decided hydremia supervenes. A 
few weeks' continuance of the ague suffices to produce decided pallor of 
the features, and surface generally, and as all watery blood is prone to 
transudation, such patients not infrequently present more or less oedema of 
the face, ankles, and other parts. Sometimes, also, especially under un- 
favorable hygienic circumstances, purpuric spots (purpura hemorrhagica) 
appear under the skin, affording additional proof of the change which the 
blood has undergone. 

In long- continued cases of malarial disease in the adult waxy degenera- 
tion of organs is apt to occur, as well as melansemia. Pigment cells, 
flakes, and particles appear in the blood, the coats of the minute arteries, 
and in various organs, as the spleen, liver, etc. In the child these results 
are more rare. 

Intermittent fever in children, if proper remedial measures are em- 
ployed at an early period, is ordinarily not dangerous, and is quite amen- 
able to treatment ; but that comparatively infrequent and fatal form of it, 
designated the pernicious, occurs more frequently in children than adults. 
In New York City, where the type of malarial diseases is mild, I have 
never met a case of pernicious intermittent in the adult, but I can recall 
to mind such cases in children, two of them fatal. This form of the fever 
occurs in a smaller proportionate number of cases in infancy than in child- 
hood, probably because the cold stage is less pronounced. In the pernicious 
ague the system is overpowered — it does not react in a degree commen- 
surate with the intensity of the disease. The patient enters the cold stage, 
becomes stupid, and, if not relieved by prompt and efficient measures, 
passes into fatal coma. A type of the disease, therefore, which would 
not be pernicious in a robust individual, may be such in one of a broken- 
down constitution and feeble reactive power. In most cases occurring in 
children the coma is preceded by eclampsia, which is apt to be general 
and protracted. 

Eclampsia increases the passive congestion of the cerebro-spinal axis 



TREATMENT. 317 

already present in this stage, and if not speedily relieved may end in 
transudation of serum over the surface of the brain, and perhaps menin- 
geal apoplexy, causing fatal coma. This has occurred twice in my practice. 

Sometimes in young children the diagnosis of intermittent fever is 
doubtful, either because the disease has not continued sufficiently long, or 
there has not been the characteristic paroxysm. The patient may be 
feverish, and fretful, with anorexia, and evidences of headache, but with- 
out the usual distinctive symptoms. I have sometimes in such cases been 
able to establish the diagnosis by detecting enlargement of the spleen. In 
examining for the " ague cake," the child must lie quietly on its back, 
and the fingers, placed midway between the epigastrium and umbilicus, 
be carried gently but with firm pressure outward in the direction of the 
spleen, when the anterior edge of this organ wiil be felt, if it be enlarged. 
It is impossible to make the examination when the child cries, on account 
of the contraction of the abdominal muscles. 

Treatment. — It is evident that no time should be lost in applying ap- 
propriate remedies in a case of infantile ague ; for, although the first 
paroxysm may be mild, the next may be more severe, and attended by 
danger. Moreover, the sooner the disease is cured the less liable it seems 
to be to return. Therefore we prescribe at once the sulphate of quinia or 
cinchonia, one and a half grains of the latter producing the effect of about 
one grain of the former. Our experience in the children's class in the 
Outdoor Department has been chiefly with the sulphate of cinchonia, on 
account of its cheapness, and there has yet been no case of ague which it 
has failed to control. A recent writer has published statistics showing his 
success in curing intermittent fever by this agent, but nothing in thera- 
peutics is more easy than to cure this disease in our climate by either of 
the sulphates mentioned. The chief difficulty consists in preventing a re- 
turn. To an infant of two years I prescribe one grain of sulphate of quinia, 
or the equivalent of sulphate of cinchonia, three times daily, till all symp- 
toms of the ague have disappeared ; then twice a day during the subse- 
quent week, and afterward once a day for some days ; and finally twice 
•or thrice a week. It is only by the protracted use of the drug in occa- 
sional doses that the return of the intermittent can be prevented. 

It is important in administering these sulphates to infants to employ a 
vehicle which will, so far as possible, disguise the bitterness. The vehicle 
which I prefer for their administration is the elixir adjuvans or elixir 
tarax. co. The following formula is for a child of three years : 

I>. Quiniae sulpliat., gr. xij ; 

Elixir adjuvantis, 1 jss. Misce. 

The following is also a good formula : 

3 . Quinia? sulpliat., gr. xvi ; 
Ext. glycyrrhizse, 3 i ; 
Syr. rubi. idaei., 1 ii. Misce. 
(Raspberry.) 



318 REMITTENT FEVEK. 

One teaspoonful three to five times daily. The first dose should be given 
immediately after the fever abates. In this climate two or three days 
suffice to cure the disease, after which by daily but gradually diminished 
use of the medicine in the manner stated above, the return of the malady 
is prevented. Protracted cases attended by anaemia require the use of 
iron in addition to the remedy which is designed to control the disease. 



CHAPTER II 

REMITTENT FEVER. 



If a physician were to consult the standard treatises on diseases of 
children, in order to ascertain the nature of remittent fever, he would 
rise from the perusal with no clear idea of it. One tells us that the re- 
mittent fever of children is identical with typhoid fever of adults ; an- 
other, that it is a gastro-intestinal inflammation ; and, finally, Hillier be- 
lieves that there is properly no such disease, and that the term should be 
dropped from the nosology of children. There is, however, a remittent 
fever of children as well as adults, and much of the confusion which exists 
in reference to it arises from the fact that writers have not kept in view 
what constitutes a fever. 

Febrile action which has a local cause is not an essential fever, and 
should not be described as such. It happens that in children a sympto- 
matic remittent fever arises from a variety of local causes, as dentition, 
intestinal worms, subacute gastro-intestinal inflammation, etc. But all 
such cases should be excluded from our consideration of remittent fever; 
as clearly as we distinguish the continued fever of pneumonia or bron- 
chitis from that of typhus or typhoid. 

There is an essential remittent fever of children due to malaria. The 
same conditions which produce intermittent fever do, in a certain propor- 
tion of cases, produce a fever which does not intermit, but continues with 
more or less pronounced exacerbations a certain number of days, when it 
ceases or becomes intermittent. Those who practise in malarious local- 
ities notice a larger proportion of cases of remittent fever among children 
than adults, because their constitutions are less able to resist the malarial 
poison, so that an exposure which in an adult would produce milder dis- 
ease, namely, a tertian ague, is apt to cause a quotidian or remittent in 
the child. In young and feeble infants the proportionate number who 
have remittent fever is large. Cases, too, are not infrequent in localities 
not malarious, of a remittent fever, occurring more frequently in the 
spring and autumn than in other seasons. Some of these cases are per- 



SYMPTOMS — TREATMENT . 319 1 

haps a mild type of typhus, but in most instances the conditions do not 
appear to be present which ordinarily give rise to typhus, and they do not 
occur in connection with cases of typhus in adults. The cause, though 
obscure, is apparently atmospheric. 

The symptoms of remittent fever vary in different cases. The exacer- 
bations and remissions are more pronounced in some than others. Even 
in those cases in which the fever is due to paludal emanations, and occurs 
in connection with cases of the intermittent, the febrile movement may be 
almost uniform, slight exacerbations occurring in the latter part of the 
day. In other cases the exacerbations and remissions are pronounced, the 
febrile excitement abating in a perspiration. Occasionally the fever is 
higher on each second day. Cephalalgia is common, and in severe cases 
delirium and stupor are not infrequent. There may be distinct remissions 
in the beginning, and afterward, for a few days, the fever be pretty uni- 
form, when it again remits or ceases. The tongue is covered with a light 
fur. Thirst, loss of appetite, a tendency to constipation, scanty and 
high-colored urine, containing perhaps urates, and a cough due to mild 
bronchitis, are common symptoms. 

When remittent fever is due to marsh emanations, the same anatomical 
characters are doubtless present as in the adult, namely, blood containing 
more or less pigmentary matter, enlargement of the spleen, bronzing of 
the spleen, and, in severe cases, of the liver, and sometimes of the brain. 

The diagnosis is not always easy. On the one hand, local diseases 
with symptomatic remittent fever are to be excluded, and, on the other, 
typhus and typhoid. The discrimination of it from typhus and typhoid 
fevers is practically of little moment, but it is a matter of vital importance 
to make a differential diagnosis between it and the local diseases. I have 
known one of the acutest diagnosticians and most eminent physicians of 
New York mistake incipient meningitis for it, a mistake indeed not un- 
common. The points involved in a differential diagnosis will be consid- 
ered in our descriptions of the local diseases. 

Treatment. — If we have ascertained by a careful examination that 
the fever is remittent, and not symptomatic, but essential, there is one 
remedy which is required in nearly all cases, namely, quinia, or its equiv- 
alent, cinchonia. Mild febrifuge medicines, with light diet, may be first 
employed in sthenic cases, in which the pulse is full and strong, and the 
quinia given when the fever has somewhat abated. The diet should be 
bland, but nutritious, and the bowels be kept regularly open by citrate of 
magnesium or other mild aperient. Bromide of potassium or hydrate of 
chloral may be occasionally employed, as recommended in the treatment 
of typhoid fever, to produce quietude or sleep, in cases attended by de- 
lirium or insomnia. A warm mustard foot-bath and cool applications to 
the head are useful in such cases. 



320 TYPHOID FEVER 



CHAP TEE III. 

TYPHOID FEVER. 

Typhus and typhoid fevers occur in children, "but the former is mild 
and infrequent, rarely occurring except when adults of the same household 
are affected. It requires little treatment, except good nursing. Typhoid 
fever, on the other hand, is not infrequent in children, and, as it presents 
certain peculiarities prior to the age of puberty, it is proper to describe it 
in this connection. This disease is much less common in infancy than in 
childhood, and in the first half of infancy is believed to be rare. Still, 
there can be no doubt that many cases in the first years of life are not 
diagnosticated, being mistaken for subacute and protracted entero-colitis. 
It may, therefore, be more common in the infant than is commonly sup- 
posed. Its period of greatest frequency in children is between the ages 
of six and twelve years. 

Causes. — It is now generally admitted that typhoid fever is mildly 
contagious, and that its specific principle abounds largely in the dejections 
and excretions of the patient. It is uncertain whether it is communicable 
by the breath of the patient, or exhalations from his surface. If it is, it is 
slightly so, while numerous observations demonstrate its communicability 
through the use of night-stools or privies which contain the evacua- 
tions. 

There is little doubt also that typhoid fever originates de novo, caused 
by the miasm produced by decaying animal or vegetable matter. Numer- 
ous cases have been observed in which it originated from defective sewer- 
age, or decaying vegetables in cellars, in localities in which no case had 
previously been observed. The germs of the disease when it originates 
under such circumstances may probably be received into the system by in- 
spiration and in the ingesta. The use of well-water which is contami- 
nated with sewer drainage has been repeatedly known to produce it. It 
has even been traced to impure water used in rinsing milk-cans which 
contaminated the milk, and to impure ice which contained the subtle spe- 
cific principle. Boys are more frequently attacked than girls ; according 
to some statistics in the proportion of three to one. Deterioration of the 
health from general causes increases the liability to be attacked. On the 
other hand, those having tuberculosis, carcinoma, heart disease, and prob- 
ably certain other visceral lesions, are more apt to escape than those in 
health. 

Anatomical Characters. — As typhoid fever is a constitutional dis- 
ease, we would expect to find early and important changes in the blood. 



ANATOMICAL CHAKACTEKS. 321 

No alteration, however, has been discovered in this fluid peculiar to typhoid 
fever. The amount of fibrin is diminished as in most of the essential 
fevers, and its coagulation is feeble, forming, when the blood stands, soft, 
small, and dark clots. When the fever has continued for some time, a 
state of anaemia more or less decided supervenes, in which the amount of 
albumen and blood-corpuscles is diminished. Although there are often 
decided symptoms referable to the nervous system, no constant changes 
have been discovered in the brain or spinal cord. The changes observed 
in them when death has occurred in the course of typhoid fever have been 
for the most part due to other causes. It is different with the respiratory 
system. After the first week of typhoid fever bronchitis is almost as con- 
stant as inflammation of the fauces in scarlet fever, and accordingly we 
find in fatal cases redness and thickening of the bronchial mucous mem- 
brane, which is covered with a viscid and ordinarily scanty secretion. 
Hypostatic congestion of the lungs, with more or less oedema, and in 
severe and enfeebled cases hypostatic pneumonia, are not uncommon. In 
the bronchitis and state of feebleness we have the causes of pulmonary 
collapse, and this lesion is not infrequent over limited portions of the 
lungs, especially if the bronchitis affect the smaller tubes. 

The lesions occurring in the digestive system are important. The mu- 
cous membrane of the small intestine is more or less injected, and at an 
early period, even by the second or third day, the patches of Peyer, soli- 
tary glands, and at the same time the mesenteric, begin to enlarge. It has 
been stated by high authorities that the enlargement is due to infiltration 
with a peculiar substance, which has been termed the typhus material. 
I have made microscopic examination of these glands in typhoid fever of 
the adult, and have found a considerable increase of the small round granu- 
lar cells of which they are composed. I do not, therefore, doubt that 
the enlargement is due mainly to hyperplasia of the cellular elements of 
the glands, though there is probably infiltration to a certain extent of 
inflammatory products between the cells. The mucous membrane over the 
glands undergoes inflammatory thickening and softening. In the adult, 
sloughing of this membrane is frequent, with the disintegration of the 
glands and their elimination into the intestines, producing ulcers, small 
and circular, corresponding with the site of the solitary glands, large and 
oval or irregular, corresponding with the site of the agminate. Disinte- 
gration of these glands and the formation of ulcers are less frequent in 
children than in adults. In the adult, who recovers, the mesenteric glands, 
and those of the solitary and agminate which are not destroyed, return to 
their normal state by fatty degeneration, liquefaction, and absorption of the 
redundant cells. In the child this is the common result, instead of slough- 
ing and disintegration, as regards both the solitary and agminate glands, 
and uniform result as regards the mesenteric, and I may add bronchial 
glands, which are also in a state of hyperplasia. The absence of ulcer- 
21 



322 TYPHOID FEVER. 

ation or its slight extent affords explanation of the fact that intestinal per- 
foration is very rare in children. 

The spleen gradually enlarges, often to twice the normal size, has a 
dark-red color, and is softened. Enlargement of the spleen possesses 
great diagnostic value in those cases in which the diagnosis is obscure. 
For while very similar intestinal lesions may occur in chronic entero-colitis, 
the coexistence of these lesions with the splenic enlargement and soften- 
ing shows the constitutional nature of the malady. 

In cases which are severe, and which present a decidedly adynamic 
type, the muscles become soft and flabby, the action of the heart is feeble r 
and more or less passive congestion of the viscera results. In such cases 
congestion of the kidneys and albuminuria are not infrequent. 

Symptoms. — Typhoid fever has a prodromic stage of a few days, some- 
times of a week or more, in which the child appears languid, indisposed 
to play, and has little appetite, but complains of no pain unless occasional 
slight headache, and has no symptom which would lead the friends or even 
physicians to suspect the grave nature of the disease which impended. 
By and by a slight fever occurs. 

The febrile movement, which gradually becomes more pronounced, re- 
mits, but does not cease in the morning, and has evening exacerbations. 
After the first week of fever the remissions are less marked, but the fever 
is not uniform at any period in its course. Hence some of our ablest 
writers on diseases of children continue to designate typhoid fever of chil- 
dren remittent fever, fully aware of its identity with typhoid fever of the 
adult. As the case advances, the appetite fails, all solid food being re- 
fused, and liquid food being taken more from thirst than hunger. The 
tongue in the first week, and in some patients throughout the course of the 
disease, is covered with a light moist fur, while in others having a graver 
type of the fever the tongue after the first week is dry and brown. During 
the prodromic period, and in the first week, the bowels act regularly, or 
are slightly relaxed, and they are readily affected by purgative medicines. 
After the first week there is in most children a tendency to diarrhoea,, 
which requires now and then the use of astringents, the stools being 
watery and brown, or dark yellow. The abdominal walls are seldom re- 
tracted, but prominent, especially after the first week, in consequence of 
meteorism, which is present in children as well as adults. Sometimes there 
is apparent tenderness, when pressure is made over the right iliac region, 
but this must not be confounded with hyperesthesia, which is common in 
the commencement of febrile diseases in children, and which is observed 
especially upon the abdomen, chest, and inner part of the thighs. 

The respiration in the first week is slightly accelerated, as it is in all 
febrile diseases. In the second week, and subsequently when bronchitis 
is developed, the respiration is ordinarily more accelerated, though not in 
a marked degree, unless in those exceptional instances in which there is an 



SYMPTOMS. 323 

abundant collection of mucus in the smaller bronchial tubes. A cough is 
often present, dependent on the bronchitis, and varying in character ac- 
cording to the degree and stage of the inflammation. In the first days of 
the fever it is infrequent, and hacking ; at a later stage it is more frequent, 
and not so dry, though in cases of ordinary severity the amount of expec- 
toration is inconsiderable. Hypostatic congestion, oedema, hypostatic 
pneumonia, splenization, or thickening of the alveolar walls, and col- 
lapse, which may, and some of which not infrequently do, occur in the ad- 
vanced disease, increase, more or less, the frequency of the respiration and 
the cough, and modify the physical signs. 

The pulse in the first week, in ordinary cases, is from 100 to 110 or 115. 
It gradually becomes more accelerated, numbering in the second week 123 
or more ; in grave cases even 160. The more frequent the pulse, the 
greater the danger and more unfavorable the prognosis. During the 
exacerbations the number of pulsations per minute is 15 or 20 more than 
in the remissions. The change in temperature corresponds with that of 
the pulse, being from l c to 2° higher in the exacerbation than remission. 
The extremes of temperature in cases of ordinary severity are about 101° 
and 104°. A temperature above 105° shows a grave, probably a malig- 
nant, type of the disease, or else a serious complication. 

There is great variation as regards the symptoms referable to the ner- 
vous system. Headache is common in the prodromic and initial stamps, 
after which it ceases. A few are delirious even from an early period, 
screaming loudly, or muttering incoherently, but the majority are quiet, 
having, indeed, a degree of mental dulness, but being able to appreciate 
questions when aroused, and answering correctly. Subsultus tendinum 
and carphologia, which some exhibit, show that there is profound dis- 
turbance of the nervous system. Epistaxis occurs occasionally in the first 
week, as in the adult, but is not abundant. 

The rose-colored eruption appears in children as well as adults between 
the sixth and twelfth days, but is more frequently absent in the former 
than the latter ; sometimes the number of spots is less than half a dozen. 
Sudamina are common in the second and third weeks, and perspirations 
may occur at any time in the course of the fever, but without ameliora- 
tion of symptoms. More or less deafness is common, being in most in- 
stances a purely nervous symptom, without, therefore, any structural 
change in the ear, but it is possible, as has been suggested by certain 
writers, that it sometimes results from inflammatory thickening of the 
Eustachian tube or external meatus, or to a weakened and flabby state 
of the muscles of the ear. 

The duration of typhoid fever is not uniform ; while mild cases may end 
in two weeks, those of a severer type continue three or even four. The 
patient becomes progressively more emaciated and feeble. In protracted 
and severe cases his condition seems very unpromising to one not familiar 



324 TYPHOID FEVER. 

with the clinical history of the fever. Pale, emaciated, and feeble, prob- 
ably passing his evacuations in bed, taking little notice of objects around 
him, he presents, at the close of the third week, an appearance of help- 
lessness, notwithstanding the best of nursing, and the constant employ- 
ment of sustaining measures, which is truly discouraging. 

Complications. — The chief complications of typhoid fever are broncho- 
pneumonia, already sufficiently described, enteritis, intestinal haemorrhage, 
peritonitis, otitis, parotiditis, and muguet. In one instance I lost a patient 
about ten years old, in whom the fever had nearly terminated, by the sud- 
den accession of croup. There is, as we have seen, in ordinary cases, 
more or less inflammation of the mucous membrane of the air-passages, 
and of the intestines, especially, in the vicinity of the patches of Peyer. It 
is easy to understand how, under circumstances which may arise in the 
fever favorable to the development of mucous inflammations, the bronchitis 
and enteritis may so increase as to constitute complications. They are the 
most frequent of the serious complications. 

Feeble action of the heart, common in severe cases of typhoid fever, 
and which after the second week is partly attributable to granulo-fatty 
degeneration in the muscular fibres of the heart, which is frequent in 
grave forms of the infectious diseases, obviously favors the occurrence of 
bronchial and pulmonary congestion. Hence the proneness in these cases 
of the inflammation to extend downward from the larger to the smaller 
bronchial tubes and to the lungs, so that broncho-pneumonia becomes an 
occasional very grave complication. 

In the child as well as adult the mucous membrane of the lower part of 
the ileum in the vicinity of Peyer' s patches is apt to be thickened and 
hyperaemic, a true intestinal catarrh. It is easy to understand how under 
certain circumstances this may become aggravated, so as to constitute an 
intestinal inflammation of considerable extent and gravity, a severe entero- 
colitis, so that the local symptoms predominate over the constitutional and 
aggravate the latter. 

In the adult, as is well known, the Peyerian and solitary glands becom- 
ing more and more prominent by proliferation of their cellular elements 
(the lymphoid cells) begin to ulcerate in the second week, and slough in 
the third, forming the typhoid ulcer, which is slow in healing, and aids 
in keeping up the diarrhceal state. Although such destructive or necrotic 
inflammation is rare in young children, it may occur in those of a more 
advanced age. 

Intestinal haemorrhage is therefore an occasional accident. Hillier met 
four cases in thirty of the fever. It indicates the presence of ulcers upon 
the surface of the intestines. The younger the child, the less the liability 
to it. Some, in whom it has occurred, recover, but others die. 

Intestinal perforation is more rare in children than in adults, as might 
be inferred from the statement already made, that intestinal ulceration is 



DIAGNOSIS. 325 

less frequent and extensive in thcrn. Statistics show that perforation oc- 
curs only once in 232 cases. Therefore, as perforation is the common 
cause of peritonitis in this disease, this inflammation is a rare complication. 
Peritonitis may, however, occur in typhoid fever without perforation. In 
one such case (an adult) in the fever wards attached to Charity Hospital, 
local peritonitis with fibrinous exudation occurred opposite two ulcerated 
patches of Peyer, the ulcers extending nearly to the peritoneum, but not 
perforating. The lesions observed in this case throw light on those cases 
of peritonitis complicating typhoid fever which recover, the cause of 
which has received a different explanation. 

In advanced and greatly debilitated cases, thrush sometimes appears in 
the interior of the mouth, and upon the fauces. It is always an unfavor- 
able prognostic symptom in children suffering from chronic or protracted 
disease. Parotiditis is also a rare complication. Otitis, commencing 
with pain, and producing a discharge which may continue for weeks, is 
not rare, though less frequent than in scarlet fever. The otitis is com- 
monly external, but it may, in scrofulous subjects, extend to the mid- 
dle ear. 

Diagnosis. — This is more difficult in children than in adults, and the 
vounger the child the greater the difficulty. In infants protracted entero- 
colitis, with febrile action and dry furred tongue, cannot in certain cases 
be positively diagnosticated from typhoid fever by the symptoms and 
clinical history. Typhoid fever is believed, however, to be rare at this 
age, for an infant nourished at the breast, and rarely drinking from a cup, 
is very seldom exposed to the cause of the disease. When, however, as 
now and then happens, a young child presents the symptoms characteris- 
tic of protracted subacute entero-colitis, or typhoid fever, and older mem- 
bers of the household have the fever, it is highly probable that the case is 
one of the latter disease, and it should be treated accordingly. 

Even in older children typhoid fever is apt to be mistaken for simple 
subacute enteritis, or entero-colitis, or vice versa. The following facts aid 
in the differential diagnosis. In typhoid fever there is total loss of ap- 
petite, while in the subacute intestinal inflammation food is not entirely 
refused. Diarrhoea commences early in the inflammation, while in the 
fever it is not ordinarily till after the lapse of a few days. Abdominal 
tenderness in the fever is not appreciable, or is located in the right iliac 
region ; in the other disease it is general over the abdomen, or located in 
the umbilical region. In typhoid fever there is bronchitis with a cough 
which is absent in the inflammation. In typhoid fever there are certain 
other symptoms, more or fewer of which are present in most cases, and 
which do not occur in the intestinal diseases, except as a coincidence ; 
for example, headache, epistaxis, stupor, delirium, and perhaps the rose- 
colored spots. 

Typhoid fever may be mistaken for meningitis, during the first week, 



326 TYPHOID FEVER. 

but in meningitis there is more constipation, irritability of stomach, and 
less elevation of temperature. Moreover, in meningitis, at a compara- 
tively early stage, we are able to detect patches of congestion of the fea- 
tures coming and disappearing suddenly ; and slight inequality of the 
pupils, or their oscillation when the light is uniform ; signs which are 
lacking in typhoid fever. In a doubtful case the ophthalmoscope might 
be employed, which in meningitis discloses congestion of the vessels of 
the retina, oedema, etc., anatomical changes which do not pertain to 
typhoid fever. 

The differential diagnosis of typhoid fever and acute tuberculosis may 
be made by attention to the following points. In tuberculosis there is 
cough, with some acceleration of respiration from the first, without epis- 
taxis, stupor, or other nervous symptoms, and without the abdominal 
symptoms which are so prominent in the fever. 

Duration. — The duration of typhoid fever varies from two to about 
four weeks, but complications which may arise may protract the febrile 
movement. Recovery from a severe and protracted attack is slow, several 
weeks or even months elapsing before complete restoration to health. A 
tendency to diarrhoea often continues several weeks after the fever proper 
ceases, necessitating a rigid oversight of the diet, and the occasional em- 
ployment of astringents. 

Prognosis. — A much larger percentage of children recover than of 
adults. Although there be great emaciation with loss of strength, recovery 
may be confidently predicted, provided that no serious complication oc- 
curs. In fatal cases which I have met, the unfavorable result occurred 
as a rule from the complications, rather than directly from the malady. 
The condition in which severe typhoid fever leaves a patient is favorable 
to the development of tubercles, and now and then they occur, disappoint- 
ing our expectations and prediction of recovery. 

Treatment. — Typhoid fever, like typhus, cannot be abridged by treat- 
ment, and the indication is to sustain the vital powers, diminish the in- 
tensity of the febrile movement, and to control any untoward symptom or 
complication. Quinia, so useful in malarial diseases, may be administered 
in small doses for its tonic effect, and as an aid in promoting digestion. 
It is commonly and properly prescribed in some convenient vehicle for this 
purpose, but it does not antagonize the typhoid, as it does the malarial 
poison. Perturbating medicines, and especially cathartics, should be 
given with caution. The tendency to intestinal ulceration and haemor- 
rhage, and the asthenic nature of the fever, require abstinence from or 
cautious use of such agents. A temperature remaining under 103° 
usually involves little danger. If it rise above that, antipyretic measures 
should be employed. The use of salicylate of sodium, large doses of 
quinine, and cold-water ablutions, are the three admissible remedies for 
this state. The salicylate I suspect impairs the appetite, and retards 



TREATMENT. 327 

digestion, and the quinine is much less efficient as an antipyretic in this 
fever than cold-water bathing. I therefore order the nurse to bathe fre- 
quently the forehead, face, hands, arms, neck, and sometimes the chest, 
with cold water, to which it is proper to add alcohol or some spirituous 
[lotion. A cloth wrung out of ice water or an ice bag should be applied 
over the head, and the hands may be allowed to lie a considerable time in 
a wash-bowl containing the lotion, which is always grateful to the 
patient. The water treatment thus applied will usually reduce the tem- 
perature one, two, or three degrees within a few hours. 

In all cases of typhoid, as in other essential fevers, free ventilation is re- 
quired from an open window, and the bedding and body linen should be 
changed every day. 

Observations made during the last dozen years appear to show that the 
mineral acids have a salutary effect upon the course of the fever. 

The dilute nitric, muriatic, or nitro-muriatic acid should be given 
largely diluted with water, and, if possible, through a glass tube so as to 
protect the teeth. I have recently administered the dilute muriatic acid 
in the acidulated liquid pepsin prepared by Mr. Kress, of Fifty-second 
Street and Broadway, in the treatment of typhoid fever. One ounce 
of the liquid contains 30 min. of the dilute acid, and one teaspoonful can be 
given every third hour to a patient of five years. The scanty secretion 
of gastric juices in this disease, the poor appetite and slow digestion, in- 
dicate the need of such medicine, and thus far the result has been good. 

If the pulse be rapid and weak, or fluctuating, digitalis meets the special 
indication, and it can be administered with or between the doses of 
quinine. As there is great proneness to diarrhoea and intestinal ulcera- 
tion, the selection of the proper diet is important, and of all the dietetic 
articles milk is the one upon which we must chiefly rely for the suste- 
nance of the patient. While it contains the desired nutriment it is easy 
of digestion, and possesses, when fresh aud of good quality, no irritating 
property which would aggravate the intestinal disease. The meat broths 
or juices, fresh eggs beaten up in milk, farinaceous foods, as barley, wheat, 
or rice flour in the milk, are proper adjuvants to the milk diet. The dry 
state of the mouth, and scanty secretion of saliva, and probably also of 
the pancreatic juice by which starch is digested, show, however, that only 
a moderate amount of farinaceous food can be assimilated during the 
fever. The patient may be allowed to drink cold water in moderate 
quantity. 

Mild cases of typhoid fever do not require alcoholic stimulants, but 
they are useful in severe cases in the form of wine whey or milk punch, 
especially in the third and fourth weeks, and during convalescence. 
When the pulse is feeble and quick, the mind wandering and the fingers 
■tremulous, the regular and judicious use of alcohol aids materially in sus- 
taining the vital powers during the critical period. 



328 CEREBR0-SP1NAL FEVER. 

The complications which may arise in the course of the fever require 
prompt treatment. For diarrhoea opium and bismuth are needed ; for in- 
testinal haemorrhage an ice bag over the right iliac region, and internally 
opium with acetate of lead, or with a large dose of sub nitrate of bismuth, 
or small and repeated doses of turpentine. A one-grain ergotine pill 
every fourth hour to a child of eight years, also aids in arresting the 
haemorrhage. But intestinal haemorrhage as a result of typhoid ulcera- 
tions is much more rare in children than in adults. Bronchitis and 
pneumonia require mildly irritating poultices, with the oil- silk jacket. 

Typhoid fever may relapse, but the second attack is commonly milder 
than the first. Nevertheless on account of the liability of its return, the 
patient should be quiet and free from perturbating influences during con- 
valescence. 

To guard against the spread, of the disease, the stools should always be 
promptly disinfected, by adding to the night-stool carbolic acid and a 
solution of the sulphate of iron, or a solution of the chlorides, and all 
soiled linen should be placed in boiling water. 



CHAPTEK IV. 

CEKEBRO-SPINAL FEVER. 

Cerebro-spinal fever, designated also spotted fever, tetanoid fever, 
and cerebro-spinal meningitis, is an epidemic constitutional disease, mani- 
festing itself by lesions and symptoms which pertain chiefly to the nervous 
system. Descriptions of occasional epidemics, which appear to have been 
of this malady, have been left us by writers as far back as the fifteenth 
century, but it was not clearly distinguished from typhus on the one hand, 
and local inflammatory affections of the cerebro-spinal axis on the other,, 
till after the present century commenced. 

In New York City only two epidemics of this disease have occurred 
within the recollection of the oldest physicians, one commencing in the 
autumn of 1871, and ending with the occurrence of warm weather in 
1872 ; the other beginning in the autumn of 1880, and ending about the 
month of May, in 1881. The number of cases was considerably greater 
in the former than the latter epidemic. 

Few diseases more urgently demand elucidation than this, for while it 
is very fatal, there is discrepancy in the views of physicians in regard to 
its cause, nature, and proper treatment. As cerebro-spinal fever results 
from some pervading cause, probably as we will see atmospheric, we would 
expect to observe effects of this cause, in some other way, in addition to- 
the disease of which we are treating. Accordingly, the histories of at 



CEREBRO-SPIXAL FEVER. 329 

least a portion of the epidemics of cerebro-spinal fever show an unusual 
prevalence of pneumonias of an ataxic type, and sometimes also of 
pharyngitis, in addition to the cerebro-spinal disease, and this disease 
is sometimes complicated by congestion and less frequently by inflamma- 
tion of the lungs. The prevalence of typhoid pneumonias during cerebro- 
spinal fever was long ago observed. Thus, in Bascome's history of epi- 
demics, it is stated that " epidemic encephalitis and malignant pneumonias 
prevailed in Germany (Webber) in the sixteenth century." In this 
country, in the epidemics of cerebro-spinal fever from 1811 to 1815, 
pharyngeal and pneumonic inflammations were unusually frequent. In 
more recent epidemics observers have not so often, but have occasionally, 
recorded the prevalence of pneumonias in connection with cases of the 
cerebro-spinal disease. Accordingly, Webber, who has examined the 
histories of the various epidemics, describes in his prize essay a second 
variety of cerebro-spinal fever, which he designates pneumonic, in which 
the cerebro-spinal axis is involved but slightly, or not at all, and the 
brunt of the disease falls upon the respiratory organs. In certain epi- 
demics, according to him, the pneumonic form is common, while in others 
it is infrequent. 

During the time when the epidemic of ] 872 in New York City was at its 
maximum, an unusually large number of cases of pleuro-pneumonia of an 
asthenic type, and I may add, I think, of pharyngitis, occurred ; and 
while cerebro-spinal fever rarely affected those above the age of fifty years, 
many of those with pneumonia were old people. According to the 
statistics of the New York Health Board, there were 1707 deaths from 
diseases of the respiratory organs, exclusive of phthisis, during the four 
months from February 1st to June 1st, 1872, when the epidemic of 
cerebro-spinal fever was at its height, while during the remaining eight 
months of the year there were only 1336 deaths from the same diseases ; 
and I need not add that deaths from affections of the respiratory apparatus 
are largely from pneumonia. Moreover, I am of opinion, from my own 
observations, that many of the cases of pneumonia, during that period, 
presented symptoms of greater gravity than usually accompany this form 
of inflammation of the same extent. The patients were greatly prostrated 
from the first, and in some of them febrile movement, muscular pains, 
restlessness, or delirium preceded for hours or even days the pneumonic 
symptoms, affording evidence that the lung disease, if not due entirely to 
the same atmospheric conditions which give rise to cerebro-spinal fever, 
was at least under their influence. Although it is probable that pneu- 
monia occurring during an epidemic of cerebro spinal fever is in most 
instances a strictly local malady, as it is at ordinary times, more or less 
modified perhaps by the epidemic influence, there can be little doubt that 
^Yebber , s view is correct, that there are occasional cases of true cerebro- 
spinal fever, in which the local manifestations are chiefly in the lungs : 



330 OEREBRO-SPINAL FEVER. 

<sases in which the cerebrospinal affection is of less importance apparently 
than the pulmonic. I might relate striking examples, observed in the 
New York epidemic of 1872. 

In one case three prominent physicians, one of them known throughout 
the country as an excellent diagnostician, pronounced the disease cerebro- 
spinal meningitis, but on the sixth day, the cerebro-spinal symptoms 
having considerably abated, pneumonia occurred, and afterward the pul- 
monary symptoms predominated. 

Cause. — Does the cause of cerebro-spinal fever emanate from the soil ? 
Facts show that it does not. Most of the epidemics commence in winter 
when the ground is frozen ; the disease occurs in valleys, and on hilltops, 
and upon all varieties of soil ; it invades one district, passes over another 
adjoining, and affects, perhaps, a third beyond, although the geological 
formation of all is the same. 

Does the cause exist in the diet, as some competent observers have sup- 
posed ? The following facts, I believe, are sufficient to justify a negative 
answer : Of two adjacent localities, in which the nature of the diet of the 
inhabitants is the same, one escapes and the other is visited by the epi- 
demic ; an epidemic sometimes prevails here and there over an area of 
many thousand miles, as recently in North America. It is hardly reason- 
able to suppose that any deleterious property would occur in the food over 
so wide a territory. An epidemic ceases, although the food of the people 
continues the same. Infants at the breast, having only the mother's milk, 
are sometimes affected, and likewise certain animals, whose food is very 
different from that of man, and finally the most careful examinations have 
hitherto failed to discover any change in the cereals, or other food, or 
noxious principle sufficient to explain the occurrence of the disease over a 
wide extent of territory. 

There can, therefore, be little doubt that the cause exists in the atmos- 
phere, though so subtle that we may never be able to detect it. Cerebro- 
spinal fever is, indeed, one of many examples in corroboration of the state- 
ment made by Humboldt, that there is no subject of scientific inquiry 
more obscure than the laws which control epidemics. Among the meteor- 
ological conditions which favor the occurrence of this disease, cool weather 
has already been alluded to. Statistics collected in France and the United 
States show that, while 166 epidemics occurred in the six months com- 
mencing with December, only 50 occurred in the remaining six months of 
the year. According to Professor Hirsch, whose statistics were obtained 
largely from central Europe, there were 57 epidemics in winter or winter 
and spring, 11 in spring, 5 between spring and autumn, 4 commencing in 
autumn and extending into winter or winter and spring, aDd 6 lasting 
through the entire year. 

All observers have remarked the fact that an ti- hygienic conditions, 
though obviously subordinate to the unknown atmospheric cause, never- 



CAUSE. 331 

theless strongly predispose to this disease. Hence, soldiers in barracks 
and the poor in tenement houses suffer most severely. During the epidemic 
of 1872, in New York, unusually severe or multiple cases occurred for the 
most part where there were obvious anti-hygienic conditions, as in apart- 
ments which were unusually crowded and filthy, or in tenements around 
which refuse had collected or which had defective drainage. The inter- 
esting chart, prepared under the direction of Dr. Moreau Morris for the 
Health Board, shows that comparatively few cases occurred in those por- 
tions of the city where the sanitary conditions were good. I cannot, how- 
ever, agree with Professor Hirsch that the greater crowding, domiciliary 
and personal uncleanliness, and imperfect ventilation in the cool than in 
the warm months, explain the fact that epidemics occur chiefly in winter 
and early spring ; for in clean and well-ventilated apartments, in sparsely 
settled and salubrious localities, epidemics occur for the most part in these 
seasons. Anti-hygienic conditions probably predispose to this disease in 
the same way, and no more than to any other grave epidemic which hap- 
pens to be prevailing, as, for example, to Asiatic cholera, whose ravages 
are largely in the crowded and uncleanly quarters of the poor. 

Is cerebrospinal fever 'propagated by contagion ? — It is the almost unan- 
imous opinion of those who are most competent to judge from their 
observations, that it is either not contagious or is so only in a very slight 
degree. It is certain that the vast majority of cases occur without the 
possibility of personal communication. Thus, in the commencement of an 
epidemic, the first patients are affected here and there at a distance from 
each other, often miles apart, and throughout an epidemic usually only 
one is seized in a family. Children may be around the bedside of the 
patient, passing in and out of the room without restriction, and yet we 
can confidently predict that none of them will contract the disease if there 
are proper ventilation and cleanliness. And when two or more cases oc- 
cur in a family, it commences at such irregular intervals in the different 
patients that the presumption is strong that they receive it from the same 
extraneous source, and not one from the other, for contagious diseases 
usually have a pretty uniform incubative period. Thus, in the Brown 
family, treated by the late Dr. Sewall {N. Y. Med. Rec, July, 1872), the 
first child sickened January 30th, and the remaining five children at inter- 
vals respectively of 5, 7, 11, 25, and 45 days. The following have been 
my observations relating to this point : 

Single cases, No. 39 (4 adults). 

Two in a family, No. 16 (8 families). 

Three in a family, No. 3 (1 family). 

In most of the 39 families in which single cases occurred, there were 
children who were allowed free intercourse with the patients. Is there 
any other malady of childhood known to be infectious, which affords such 
a record of non-contagion ? In those instances in which two in a family 



CEREBRO-SPINAL FEVER. 

took the fever, those who were last attacked did not seem to receive it 
from those who were first affected, for the reason already stated, namely, 
the very variable intervals between the two cases in the different families. 
The facts, in the family in which three cases occurred, did seem to lend 
support to the doctrine of contagion. A boy, twelve years of age, died of 
cerebro-spinal fever, and was buried on Saturday or Sunday. On the 
following Monday the mother washed the linen of the boy, which had 
accumulated, and within two days was herself affected with the disease. 
She and her infant, who was also seized with it, died. Were such cases 
frequent or not infrequent, the argument in favor of contagion would cer- 
tainly be strong ; but as they are infrequent, it is proper to accept any 
other reasonable explanation instead. The state of the bedding and 
apartments, as observed by me, was such as to render the atmosphere in 
which this family lived noxious in a high degree, and therefore such as to 
attract the prevailing epidemic. Moreover, the mother, exhausted by her 
long watching, and deprived of needed sleep (for the boy was several days 
sick), instead of obtaining the required rest, rendered her system more 
liable to the fever by her self-imposed duties on the day following the 
burial. These manifest anti-hygienic conditions appeared quite sufficient,, 
without the aid of any contagious principle, to explain the occurrence of 
the cases in this severely-visited family. My statistics, therefore, har- 
monize with the doctrine of non-contagiousness, but it is obviously very 
difficult to determine from clinical experience whether an epidemic con- 
stitutional disease is absolutely non-contagious, or contagious in a very 
low degree. Experience shows that the attendants upon a case of cerebro- 
spinal fever have immunity, unless the hygienic conditions are very bad. 

Allusion has been made to the fact that this malady sometimes occurs 
among the lower animals. In the epidemic of 1 81 1 , in Vermont, Dr. Gallop 
remarks that even the foxes seemed to be affected, so that they were 
killed in numbers near the dwellings of the inhabitants. The New York 
epidemic of 1871-72, it is well known, prevailed among horses several 
months before it occurred among the people. It was common and fatal 
in the large stables of the city car and stage lines in 1871, while among 
the people the epidemic did not properly commence, although there were 
previously isolated cases, till January, 1872. It has been asked whether 
in epidemics like this, in which the lower animals are first affected, the 
disease may not be communicated from them to man ? This obviously 
brings up the question of contagiousness. From my own observations I 
should certainly answer in the negative, for I have not been able to ascer- 
tain that those who had charge of the affected horses in the recent epi- 
demic, as the veterinary surgeons or stablemen, were any more liable to 
the fever than others who were not so exposed. They apparently were 
not, and we must, therefore, believe that this disease is not propagated 
from one species of animals to another, certainly no more than from one 



sex. 333 

animal to another in the same species, and the fact that different animals 
are affected by the epidemic is due to the potent and pervading nature of 
the cause. Cerebro-spinal fever is indeed, so to speak, pandemic in a 
double sense ; on the one hand affecting both sexes, different ages, and all 
conditions of people over a wide extent of territory, and on the other 
hand different species of animals, but with little or no contagiousness. 

Not infrequently we are able to discover some exciting cause of the 
fever, usually an exhausting or perturbating influence of some sort. An 
individual whose system is affected by the epidemic influence, and is there- 
fore predisposed to the disease, may, perhaps, escape by a quiet and regu- 
lar mode of life; but if there be an exciting cause of the nature alluded 
to, the fever may be developed. Among these exciting causes may be 
mentioned over-work, fatigue, mental excitement, prolonged abstinence 
from food, followed by over-eating, and the use of indigestible and im- 
proper food. Thus in one instance in my practice, a delicate young 
woman at the head of one of the departments in a well-known Broadway 
store, was anxious and excited and her energies overtaxed at the annual 
reopening. Within a day or two subsequently the disease commenced. 
Another patient, a boy, was seized after a day of unusual excitement and 
exposure, having in the mean time bathed in the Hudson when the weather 
was quite cool. During the recent epidemic in New York those children 
seemed to me especially liable to be attacked who were subjected to the 
severe discipline of the public schools, returning home fatigued and hungry, 
and eating heartily at a late hour. In one instance which I observed, a 
school girl of ten years returned from school excited and crying, because 
she had failed in her examination and was not promoted. In the evening, 
after she had closely studied her lessons, the fever commenced with violent 
headache. Dr. Frothingham (Am. Med. Times, April 30, 1864) writes as 
follows of the brigade in which cerebro-spinal fever occurred in the Army 
of the Potomac : ' ' Under Gen. Butterfield, a stern disciplinarian .... 
the men were drilled to the full extent of their powers — often to exhaus- 
tion. I did not at the time recognize this as the cause of the disease in 
question, but I learned that in the present epidemic in Pennsylvania the 
attack generally follows unusual exertion and exposure to cold." Observ- 
ers have long recognized the fact of such exciting causes. Dr. Gallop, in 
his history of the epidemic of Vermont, in 1811, directs attention to the 
severity of the disease among the troops under General Dearborn, who 
were fatigued by marches, and greatly dispirited by a repulse which they 
had sustained from the British. 

Sex. — It is stated by writers that more males are affected than females. 
Hospital and military statistics show this ; but in family practice, in which 
a large proportion of the patients are children, the number of males and 
females is about equal. Thus in 75 cases occurring in the 20th and 2 2d 
wards, mainly in the practice of two other physicians and myself, I find 



334: CEREBRO-SPINAL FEVER. 

that there were 39 males and 36 females. Sixty -four of these were chil- 
dren. From January 1st to November 1st, 1872, 905 cases in which the 
sex was stated were reported to the Health Board. Of these, 484 were 
males and 421 females. Dr. Sanderson's statistics of the epidemic in the 
provinces around the Vistula, the cases being chiefly children, give also 
but a slight excess of males. Probably, therefore, the sex under the age 
of puberty makes no difference in the liability to this disease, and the 
same may be said of all other constitutional affections. Men are more 
liable than women, only when they lead a more irregular life, and are 
subject to more privations and exposures. 

Age. — Children, as already stated, are much more apt to contract 
cerebro-spinal fever than adults. The following are the statistics of the 
Health Board relating to this point, the cases occurring in 18*72 : 

Under 1 year 125 

From 1 to 5 years, 336 

5 " 10 " 204 

" 10 *' 15 " 106 

" 15 " 20 " 54 

" 20 " 30 " 79 

Over 30 years, 71 

Total 975 

In the statistics which I have obtained of 81 cases occurring in the 20th 
and 2 2d wards, the ages were as follows : 

Under 1 year, 8 

From 1 to 3 years 18 

3 " 5 * " 20 

5 " 10 " 17 

" 10 "15 ." 7 

Over 14 years, . 11 

Total, .......... 81 

It is seen that nearly three-fourths of the whole number of cases in the 
recent epidemic in New York City were under the age of ten years. The 
statistics of other epidemics occurring in civil practice are similar. Thus 
Dr. Sanderson, in examining the mortuary statistics of the epidemic in 
Germany, ascertained that there had been 218 deaths under the age of 
fourteen years, and only 1 7 above that age, and although this does not 
show the exact ratio of children to adults, in the entire number of cases it 
is apparent that children greatly preponderated. 

The more advanced the age after childhood, the less the liability to this 
malady ; so that after the middle period of life few cases occur, and after 
the age of fifty years there is nearly an immunity. The oldest two in 
the New York epidemics, of whose cases I have the records, had attained 
the ages respectively of 47 and 63 years. 

Symptoms. — During epidemics of cerebro-spinal fever, we are now and 



SYMPTOMS. 335- 

then called to patients who present certain of the characteristic symptoms,, 
but in so transient and mild a form that they are soon restored to health. 
The fever is said to have aborted. I have met the following cases : 

A boy of eight years, previously well, was taken with headache, vomit- 
ing, and moderate febrile movement on April 2, 18*72. The evacuations 
were regular, and no local cause of the attack could be discovered. On 
the following day the symptoms continued, except the vomiting, but he 
seemed somewhat better. On April 4th the febrile movement was more 
pronounced, and in the afternoon he was drowsy and had a slight convul- 
sion. The forward movement of his head was apparently somewhat re- 
strained. On the 6th the symptoms had begun to abate, and in about 
one week from the commencement of the attack his health was fully 
restored. 

A boy aged six years was well till the second week in May, 1872, when 
lie became feverish, and complained of headache. At my first visit, May 
14th, he still had headache, with a pulse of 112. The pupils were sensi- 
tive to light, but the right pupil was larger than the left. The bromide 
and iodide of potassium were prescribed with moderate counter-irritation 
behind the ears. The headache and febrile movement in a few days 
abated, the equality of the pupils was restored, and within a little more 
than a week from the first symptoms he fully recovered. 

Obviously the diagnosis, when symptoms are so mild, must sometimes 
be doubtful ; but as observers in different epidemics report such cases, it 
seems proper to regard them with perhaps occasional exceptions as genu- 
ine, but aborted cases. The epidemic influence acts so feebly on these 
patients, or their ability to resist it is so great, that they escape with a 
short and trivial ailment. 

Occasionally, also, during the progress of an epidemic, we meet patients 
who present more or fewer of the characteristic symptoms, but in so mild 
a form that they are never seriously sick, and never entirely lose, the appe- 
tite, but the disease, instead of aborting, continues about the usual time. 

Thus, on the 4th of January, 1873, I was called to a girl of thirteen 
years, who had been seized with vomiting followed by headache in the last 
week in December. During a period of six to eight weeks, or till nearly 
the 1st of March, she presented the following symptoms : Daily paroxys- 
mal headache, often more severe in the forenoon ; neuralgic pain in the 
left hypochondrium, and sometimes in the epigastric region ; pulse and 
temperature sometimes nearly normal, and at other times accelerated and 
elevated, both with daily variations ; inequality of the pupils, the right 
being larger than the left during a portion of the sickness. This patient 
was never so ill as to keep the bed, usually sitting quietly during the day 
in a chair, or reclining on a lounge, and she never fully lost her appetite. 
Quinia had no appreciable effect on the paroxysms of pain or fever. 

There can, in my opinion, be little doubt that this girl was affected by 
the epidemic, but so mildly that there was, for a considerable time, much 
uncertainty in the diagnosis. Cases like this, in which the disease is so 



336 CEREBRO-SPINAL FEVER. 

feebly developed, and those in which it aborts, though they deserve recog- 
nition, evidently should not be employed in the statistics. 

Mode of Commencement. — in all the cases which I have observed, 
cerebro-spinal fever commenced between 12 m. and 6 a.m., and in the 
records of cases published by others the time of commencement, so far as 
I have observed, was between the same hours. The fact that this disease 
does not commence after the repose of night till several hours of the day 
have passed, shows the propriety, as we shall see hereafter, of enjoining a 
quiet and regular mode of life, free from excitement, and with sufficient 
hours of sleep during the time that the epidemic is prevailing. 

Cerebro-spinal fever usually has no premonitory stage, or it is so slight 
as to escape notice. Exceptionally there are certain premonitions for a 
few hours or days, such as languor, chilliness, etc. Premonitions occur 
more frequently in mild than in severe forms of the fever. The ordinary 
mode of commencement in a typical or somewhat severe case is as follows : 
The patient has a rigor or chill, or rarely two or three of them at irregular 
Intervals of some hours. One patient, an adult female, had three or four 
pretty severe chills, the last occurring, from recollection, as late as the 
fourth day. Children often have clonic convulsions in place of the chill, 
or immediately after it, partial or general, slight or severe. Apathy, more 
or less profound stupor, or less frequently delirium succeeds. In the 
gravest cases semi-coma occurs, from which the patient is with difficulty 
aroused, or profound coma, which, in spite of prompt and appropriate 
treatment, may prove speedily fatal. If aroused to consciousness, he now 
complains of violent headache, with or without, or alternating with equally 
severe neuralgic pains in the neck, some part of the trunk, or in one of the 
extremities. The pupils are dilated, or less frequently contracted, and 
they respond feebly, or not at all, to light. Often they oscillate, and 
occasionally one is larger than the other. 

Vomiting, with little apparent nausea, is also an early and prominent 
symptom, evidently having a cerebral origin. It occurred as an initial 
symptom in 51 of 56 cases observed by Dr. Sanderson. Of 61 cases 
observed by Dr. Sewall and myself, neither its presence nor absence was 
recorded in 13 cases, its absence in only 1, and its presence as an early 
symptom in 48 cases. 

Unlike typhus and typhoid fevers, the temperature on the first day is 
usually as elevated as, and sometimes more so than subsequently. Indeed, 
the highest temperature which I have observed in any case was only two 
or three hours after the commencement of the attack in a child of three 
years, namely, an axillary temperature of 107-|°. 

Exceptionally the initial symptoms occur in a more gradual manner, 
becoming by degrees more severe, so that a few days elapse before they 
are so pronounced that a clear diagnosis is possible. The febrile move- 
ment, headache, neuralgic pains, lassitude, vomiting, and fretfulness, 



S YMPTOMS. 337 

though pretty uniformly present in the commencement, are not in these 
cases so severe at this period as to excite any apprehension. 

Symptoms pertaining to the Nervous ^System. — Pain, already 
described as an initial symptom, continues during the acute period of the 
malady. It is ordinarily severe, eliciting moans from the sufferer, but its 
intensity varies in different patients. Its most frequent seat is the head, 
where it may be frontal or occipital. It is described as sharp, lancinating, 
or boring. It is. also common in the neck, especially the nucha, the epi- 
gastrium, umbilical and lumbar regions, In one or more of the limbs, and 
along the spine (rachialgia) . It shifts from place to place, but it is com- 
monly more persistent in the head and along the spine than elsewhere. 
The patient, if old enough to speak, and not delirious or too stupid, often 
exclaims, " Oh, my head !" from the intensity of his suffering, but after 
some moments complains equally of pain in some other part, while perhaps 
the headache has ceased, or is milder. In few instances the headache 
is absent, or is slight and transient, while the pain is intense elsewhere. 
After some days the pain begins to abate, and by the close of the second 
week is much less pronounced than previously. Vertigo occurs with the 
headache, so that the patient reels in attempting to stand or walk. Con- 
tributing to the unsteadiness of the muscular movements is a notable loss 
-of strength, which occurs early and increases. 

The state of the patient's mind is interesting. It is well expressed in 
ordinary cases by the term apathy or indifference, and between this and 
coma on the one hand, and acute delirium on the other, there is every 
grade of mental disturbance. Sometimes patients seem totally uncon- 
scious of the words or presence of those around them, when it appears 
subsequently that they understood what was said or done. Delirium is 
not infrequent, especially in the older children and adults. Its form is 
various, most frequently quiet or passive, but occasionally maniacal, so that 
forcible restraint is required. It sometimes resembles intoxication, or 
hysteria, or it may appear as a simple delusion in regard to certain sub- 
jects. Thus, one of my patients, a boy of five years, appeared for the most 
part rational, protruding his tongue when requested, and ordinarily an- 
swering questions correctly, but he constantly mistook his mother, who 
was always at his bedside, for another person. Severe active delirium is 
commonly preceded by intense headache. In favorable cases the delirium 
is usually short, but in the unfavorable it is apt to continue with little 
abatement till coma supervenes. 

On account of the pain and disordered state of mind, patients seldom 
remain quiet in bed, unless they are comatose, or the disease be mild, or 
so far advanced that muscular movements are difficult from weakness. In 
severe cases they are ordinarily quiet a few moments as if slumbering, and 
then, aroused by the pain, roll or toss from one part of the bed to an- 
other. One of my patients, a boy of five years, repeatedly made the 
22 



338 CEREBROSPINAL FEVER. 

entire circuit of the bed during the spells of restlessness. In mild cases 
patients lie quiet, usually with their eyes closed, except when disturbed. 

All writers record a general hyperesthesia of the skin. Few patients 
that are not in a state of profound coma are free from it during the first 
weeks, and it increases materially the suffering. Frictions upon the sur- 
face, and ev r en slight pressure with the fingers upon certain parts, extort 
cries. Gently separating the eyelids for the purpose of inspecting the 
eyes, and moving the limbs, or changing the position of the head, evi- 
dently increase the suffering, and are resisted. I have sometimes observed 
such outcries from slowly introducing the thermometer into the rectum, 
that I was forced to believe that the anal, and perhaps rectal, surface was 
also hypersensitive. The hyperesthesia has diagnostic value, for there is 
no disease with which cerebro-spinal fever is likely to be confounded in 
which it is so great. It is due to the spinal meningitis, and is appreciable 
even in a state of semi-coma. 

Tonic contraction of certain muscles, or groups of muscles, is present in 
all typical cases. In a small proportion of patients it is absent, or is not a 
prominent symptom, namely, in those in whom the encephalon is mainly 
involved, the spinal cord and meninges being but slightly affected, or not 
at all. This contraction is most frequent and marked in the muscles of the 
nucha, causing retraction of the head, but it is also common in the 
posterior muscles of the trunk, producing opisthotonos, and in less degree 
in those of the abdomen and lower extremities, and hence the flexed posi- 
tion of the thighs and legs, in which patients obtain most relief. The 
muscular contraction is not an initial symptom. I have ordinarily first 
observed it about the close of the second day, but sometimes as early as 
the close of the first day, and in other instances not till the close of the 
third day. Attempts to overcome the rigidity, as by bringing forward the 
head, are very painful, and cause the patient to resist. In young chil- 
dren having a mild form of the fever with little retraction of the head, 
the rigidity is sometimes not easily detected. I have been able in these 
oases to satisfy myself and the friends of its presence, by observing the 
difficulty w r ith which the head is brought forward on presenting to the 
patient a tumbler with cold water, which is craved on account of the thirst. 
The usual position of the patient in bed is with the head thrown back,. 
the thighs and legs flexed, with or without forward arching of the spine 
(see figure). The muscular contraction continues from three to five weeks, 
more or less, and abates gradually ; occasionally it continues much longer. 
Through the kindness of Dr. Griswold, of Thirtieth Street, I was allowed 
to see an infant of seven months in the tenth week of the disease. It 
exhibited great fretfulness, decided prominence of the anterior fontanelle, 
probably from intracranial serous effusion, and marked rigidity of the 
muscles of the nucha, with retraction of the head. 

Paralysis occasionally occurs, but is less frequent than we would be 



DIGESTIVE SYSTEM. 



339 



led to expect from the nature of the lesions. It may occur early, but 
it is more frequently a late symptom. It may be limited to one or 
two of the limbs, as a leg, or arm and leg, or it may be more general. 
Thus a man treated by Dr. Law in the Dublin epidemic of 1865 could move 
neither arms nor legs, and WunderKch saw a patient who had paralysis of 
both lower extremities and a considerable part of the trunk. As the 
paralysis is due to inflammatory processes in the cerebro-spinal axis, it 
usually disappears in a few weeks as the inflammation abates, and conva- 
lescence is established, but it may be more protracted. Thus in Wunder- 
lich's case there was only partial recovery after the lapse of five months. 
Digestive System. — The tongue is ordinarily lightly covered with a 
whitish fur. Occasionally in cases attended with great prostration the 
fur is dry and brown, but only for a few days, when the moist whitish 

Fro. 15. 




fur succeeds. The habitual brownish and dry fur on the tongue, and 
sordes upon the teeth, so common in typhus and typhoid fevers, are sel- 
dom observed in uncomplicated cases of this disease. Vomiting, which I 
have described as an initial symptom, usually ceases in a few hours, or 
not till the lapse of several days, and it frequently recurs at intervals dur- 
ing the periods of recrudescence, which are common in the progress of the 
fever. 

It occurs with little effort, often like a regurgitation, ;is is common 
when this symptom has a cerebral origin. The ejecta consist at first of the 
contents of the stomach and afterward partly of bile. It does not differ 
as a symptom from the vomiting which is so common in sporadic menin- 
gitis. Having a similar origin is a sensation of faintness or depression 
referred to the epigastrium. 

The appetite is poor or entirely lost during the active period of the 
malady, and it is not fully restored till convalescence is well advanced. 
On account of the imperfect nutrition, patients progressively waste, and 
when the case is protracted there is notable emaciation. Thirst, already 
alluded to, and more or less constipation are common, but the latter 



340 CEREBliO-SPlNAL FEVER. 

readily yields to purgatives. On the other hand, diarrhoea sometimes pre- 
cedes, and accompanies the disease. I observed this in a few instances in 
1872, when the weather had become warm. The patients were young 
children. 

Pulse. — The pulse in children is constantly accelerated. Even in 
mild cases it is rarely below 100 per minute, and its ordinary range is from 
112 to 160. I have seventy-five recorded observations of the pulse in 
children who recovered, taken before there was any decided improvement. 
The maximum pulse in these observations was 168 per minute, which was 
on the first day ; the minimum 82, and the average 123. The more severe 
and dangerous the attack, the greater the frequency of the pulse, unless 
occasionally in the comatose state. But even in profound coma the pulse 
was in my observations accelerated, and as death grew near, however great 
the stupor, it was progressively more frequent and feeble. Intermissions 
in the pulse do not seem to be as frequent as in sporadic meningitis. The 
pulse is liable to daily variations in frequency, which occur suddenly and 
without appreciable cause. The following consecutive enumerations of the 
pulse in four favorable cases which I have selected as typical will give an 
idea of these variations. 

1st case, an infant of 14 months, 168, 120, 108, 120, 140, 150, 136, 
128, 120. 

2d case, an infant of 2 years, 136, 152, 130, 132, 136, 140, 152, 140, 
136, 148. 

3d case, a boy of 6 years, 120, 120, 88, 84, 92, 124, 128, 120. 

4th case, a girl of 4 years, 116, 100, 124, 116, 120, 136, 140, 128, 
128, 104. 

I have preserved observations of this symptom made daily in nine fatal 
cases, and these show similar fluctuations in the frequency of the heart's 
contractions. The patients were children, all dying comatose. The maxi- 
mum pulse in these observations was 204, which was on the first day ; the 
minimum 88, and the average 140. The following are the consecutive 
enumerations of the pulse usually made twice daily in two of these cases. 
It will be seen that there was not only greater frequency of the pulse, but 
fluctuations from day to day similar to those in the favorable cases : 

1st case, age 8 months, 204, 164, 116, 160, 164. 

2d case, age 2 years 8 months, 192, 168, 200, 152, 160. 

In most inflammatory and febrile diseases exacerbations commonly 
occur in the latter part of the day, but in this disease they do not seem 
to be influenced by the time of day, so that sometimes the temperature is 
highest and pulse most frequent in the morning, sometimes in the even- 
ing, and then again at midday. 

In favorable adult cases the pulse often remains under 100, and in cer- 
tain patients it scarcely has more than the normal frequency, but if the 



TEMPERATURE. 341 

type be severe it rises to 110, 120, or over. In the adult as in the child, 
as death approaches, the pulse becomes more and more frequent and fee- 
ble, and it seldom even in the most asthenic cases has the fulness and 
force observed in idiopathic inflammations. 

Temperature. — Certain of the older observers before the days of clini- 
cal thermometry, asserted that the temperature is not increased. North 
remarked as follows : " Cases occur, it is true, in which the temperature is 
increased above the normal standard, but these are rare ;" and Foot and 
Gallop made similar statements. I am surprised also that some of the 
recent writers state that febrile movement is often absent. Thus, in a 
well- written American treatise, bearing the date 18*73, it is stated " that 
febrile symptoms do not necessarily belong to epidemic cerebro-spinal 
meningitis as a substantive disease, for it may and not unfrequently does 
occur without exhibiting any such symptoms." (Lidell.) 

I have no doubt, from the nature of cerebro-spinal fever, and from ther- 
mometric examinations, which I have made now in more than fifty cases, 
that there is always an elevation of the internal temperature above the 
normal standard during the active period of the disease. I have never 
observed a temperature of less than 99^-° if the examination were made 
within the first fourteen days, and the reason that certain other observers 
state differently is probably because they have taken the temperature of 
the cutaneous surface, which is very fluctuating and is often much below 
that of the blood. The temperature should be ascertained per rectum, 
where it corresponds pretty nearly with that of the blood. In one instance 
I supposed that I had met a case in which the temperature was not ele- 
vated, and I cite it as showing the liability to error in the thermometric 
examinations of these cases : A female patient, forty-seven years old, three 
days sick and comatose, whom I was allowed to examine with the family 
physician, exhibited no elevation of temperature when the instrument was 
placed in the mouth and the axilla, but on introducing it into the rectum 
it rose to 99£°. 

The internal temperature, although uniformly elevated, undergoes 
greater and more sudden variations than occur in any other febrile or in- 
flammatory disease. These fluctuations, which correspond with similar 
changes in the pulse, are observed during the different hours of the same 
day. I have in the statistics of my practice 146 observations of the tem- 
perature in 35 patients taken before the close of the second week. The 
highest I have already stated in speaking of the mode of commencement, 
namely 107-|° in a child of two years. It fell a little subsequently, but 
rose again on the third day to 107°, when she died. In two other cases 
the temperature was 106° on the first day, and it did not afterward reach 
so high an elevation. One of these died on the ninth day, and the other 
in the ninth week. The next highest temperature was 105^°, also on the 
first day, in an infant of eight months, who died on the ninth day. The 



M2 CEKEhKO-SPINAL FEVER. 

first and last of these cases occurred in an old wooden tenement-house in 
the suburbs of the city and upon an elevated outcropping of rock. Wun- 
derlich has recorded a temperature of 110° in one or two cases, but so 
o-reat an elevation must be very rare in cerebro-spinal fever, and is of 
course prognostic of an unfavorable ending. 

The external temperature undergoes similar but greater fluctuations, 
rising above and falling below the normal standard several times in the 
course of the same day. Similar fluctuations occur in sporadic meningitis, 
but they are much less pronounced. The more grave the case in those 
not comatose, the greater these variations. The following is a common 
example : the patient was two years old, and the case was one of consider- 
able severity. The observations Avere made at four consecutive visits dur- 
ing the first week. The internal temperature varied from 101-^° to 104^° 
as the extremes, while that of the fingers and hand at the first examina- 
tion was 90i°, at the second 90°, at the third 103°, and at the fourth 83 c . 
Thus the temperature of the extremities at the first and second examina- 
tions was about 8° below that of health, while at the third examination it 
had risen 13°, so as nearly to equal the internal temperature, and at the 
fourth examination it had again fallen 20°, or 15^-° below the normal 
standard. The patient recovered. These sudden and great variations in 
the pulse and temperature have considerable diagnostic value in obscure 
and doubtful cases. 

Respiratory System. — The symptoms which are referable to the 
respiratory apparatus are for the most part quite subordinate except when 
an inflammatory complication occurs. The respiration in uncomplicated 
cases is quiet and easy, and a cough if present is usually slight and acci- 
dental. Intermittent, sighing, or irregular respiration is less frequent 
in cerebro-spinal fever than in sporadic meningitis, but it does occur. In 
ordinary cases the respiration is somewhat accelerated, but without any 
marked disturbance in its rhythm. In 31 observations in children who 
had the disease without complication, I found the average respirations 
42 per minute, while the average pulse was 137. It is seen therefore 
that the respiration as compared with the pulse was proportionately more 
frequent than in health. This appears to be due to the fact, that certain 
muscles which are concerned in respiration, as the abdominal and per- 
haps others, are embarrassed in their movements by the tonic contrac- 
tions. In cases of pulmonary congestion, oedema, or inflammation, of 
course, the symptoms of this affection are superadded to those of the 
primary disease. 

Cutaneous Surface. — The features may be pallid, of normal appear- 
ance, or flushed in the first days of the disease ; but in advanced cases 
they are pallid, as is the skin generally. A circumscribed patch of deep 
congestion often appears, as in sporadic meningitis, upon some parts of 
them, as the cheek, forehead, and ear, and after a short time disappears. 



CUTANEOUS SURFACE. 343 

Friction for a moment upon any part of the surface, when the tempera- 
ture is not reduced, causes the same capillary congestion, a fact to which 
Trousseau has called attention as regards sporadic meningitis. 

The following are the abnormal appearances of the skin which I have 
most frequently observed : 1st. Papilliform elevations, due to contraction 
of the muscular fibres of the corium, namely the so-called goose-skin. This 
is not uncommon in the first weeks. 2d. A dusky mottling, also common 
in the first and second weeks, in grave cases, and most marked where 
the temperature is reduced. 3d. Numerous minute red points over a large 
part of the surface, bluish spots a few lines in diameter due to extravasa- 
tion of blood under the cuticle, resembling bruises in appearance, and 
large patches of the same color, an inch or more in diameter, less common 
than the others, and usually not more than two or three upon a patient. 
These last I believe from certain observations are sometimes the result of 
bruises, which the patients receive during the times of restlessness. 4th. 
Herpes. This is common. It sometimes occurs as early as the second or 
third day, but in other instances not till toward the close of the first week 
or in the second. The number of herpetic eruptions varies from six or 
eight to a dozen or more. This affection evidently has a nervous ori- 
gin, the vesicles occurring chiefly on those parts of the surface which are 
supplied by branches of the fifth pair of nerves. Its most common seat is 
upon the lips, but I have occasionally observed it upon the mucous mem- 
brane of the nasal and buccal surfaces, upon the cheek, around the ears and 
upon the scalp. 

During the first days the skin is apt to be dry. Afterward perspira- 
tions are not unusual, and free perspirations sometimes occur, especially 
about the head, face, and neck. The quantity of urine excreted is nor- 
mal, or it may be in excess of the normal amount. It occasionally con- 
tains a moderate amount of albumen, and in exceptional instances cylindri- 
cal casts and blood -corpuscles. A deposit of urates in the urine is not in- 
frequent, but this so often occurs in inflammatory and febrile diseases 
that it is of little moment. 

Arthritic inflammation, apparently of a rheumatic character, has been 
occasionally observed. It is commonly slight, producing merely an cede- 
matous appearance around one or more joints. Thus, in one case which 
came under my notice, and which was subsequently fatal, the parents, 
who were poor, and were therefore without medical advice till the case 
was somewhat advanced, had already diagnosticated rheumatism on ac- 
count of puffiness, which they had noticed around one of the wrists. 

The organs of the special senses are more or less involved in most cases, 
and the eye and ear are not infrequently the seat of serious lesions. Taste 
and smell are rarely affected, so far as known, but it is possible that they 
may sometimes be perverted or even temporarily lost during the time of 
greatest stupor. In one case at least the smell in one nostril was entirely 



344 CEREBRO-SPINAL FEVER. 

lost. The affections of the eye and ear are the most important and inter- 
esting of those of the special senses. Strabismus is common. It may 
occur at any period of the fever, continuing a few hours or several days, 
and it may appear and disappear several times before convalescence is 
established. Occasionally it continues several weeks, but with few ex- 
ceptions the parallelism of the eyes is finally restored. In a boy of five 
years, whom I last saw three months after convalescence, there was still 
convergent strabismus of the right eye and double vision. 

Changes in the pupils are among the first and most noticeable of the 
initial symptoms, as I have already stated in describing the mode of com- 
mencement. These are dilatation, less frequently contraction, oscillation, 
inequality of size, feeble response to light, etc. Most patients present one 
or more of these abnormalities of the pupils, and they continue during the 
first and second weeks, and gradually abate as the condition of the patient 
improves. Inflammatory hyperemia of the conjunctiva often occurs. It 
commences early, and, now and then, the conjunctivitis is so intense that 
considerable tumefaction of the lids results, with a free muco-purulent 
secretion. The false diagnosis has indeed been made of purulent oph- 
thalmia, in cases in which this affection of the lids was early and severe. 
But such intense inflammation is quite exceptional. More frequently 
there is a uniform diffused redness of the conjunctiva, not so dusky as in 
typhus, and the injected vessels cannot be so readily distinguished as in 
that disease. 

In certain cases almost the whole eye (all, indeed, of the important con- 
stituents) becomes inflamed ; the media grow cloudy, the iris discolored, 
and the pupils uneven and filled up with fibrinous exudation. The deep 
structures of the eye cannot, therefore, be readily explored by the oph- 
thalmoscope, but they are observed to be adherent to each other, and cov- 
ered by inflammatory exudation. They present a dusky red, or even a 
dark color, when the inflammation is recent. Exceptionally, the cornea 
ulcerates, and the eye bursts, with a loss of more or less of the liquids and 
shrinking of the eye. But ordinarily no ulceration occurs, and, as the 
patient convalesces, the oedema of the lids, hyperemia of the conjunctiva, 
the cloudiness of the cornea, and of the humors, gradually abate, and the 
exudation in the pupils is absorbed. The iris bulges forward, and the 
deep tissues of the eye, viewed through the vitreous humor, which before 
had a dusky red color from hyperemia, now present a dull white color. 
The lens itself, at first transparent, after a while becomes cataractous. 
Sight is lost, totally and forever. This form of ophthalmia is sometimes 
rapidly developed, as in the following example : 

On July 5th, 1873, I was called to a boy, five years of age, who had 
reached the tenth day of cerebro-spinal fever without apparently any 
affection of the eyes, as both presented the normal appearance. On the 
following day the left eye was red and swollen from the inflammation and 



CUTANEOUS SUEFACE. 345 

chemosis, so that the lids could not be closed, and the media were cloudy. 
Death occurred on the same day. 

If the patient live, the volume of the eye diminishes, as the inflamma- 
tion abates, to less than the normal size, even when there has been no- 
rupture, and divergent strabismus is apt to occur. Professor Knapp, 
whose description of the eye I have for the most part followed, says : 
1 ' The nature of the eye affection is a purulent choroiditis, probably metas- 
tatic. " Fortunately so general and destructive an inflammation of the 
eye, as has been described above, is comparatively rare. On the other 
hand, conjunctivitis of greater or less severity, and hyperasmia of the 
optic disk, consequent on the brain disease, are not unusual, but they 
subside, leaving the function of the organ unimpaired. 

Inflammation of the middle ear of a mild grade, and subsiding without 
impairment of hearing, is common. The membrana tympani, during its 
continuance, presents a dull yellowish, and in places a reddish, hue. Oc- 
casionally a more severe otitis media occurs, ending in suppuration, per- 
foration of the membrana tympani, and otorrhoea, which ceases after a 
variable time. But otitis media is not the most severe affection of the 
organ of hearing. Certain patients lose their hearing entirely and never 
regain it, and that, too, with little otalgia, otorrhoea, or other local symp- 
toms, by which so grave a result can be prognosticated. This loss of 
hearing does not occur at the same period of the disease in all cases. 
Some of those who become deaf are able to hear as they emerge from the 
stupor of the disease, but lose this function during convalescence, while 
the majority are observed to be deaf as soon as the stupor abates and full 
consciousness returns. 

Two important facts have been observed in reference to the loss of hear- 
ing in these patients, namely, it is bilateral and complete. When first 
observed it is in some, as stated above, complete, but in others partial, and 
when partial it gradually increases till after some days or weeks, when it 
becomes complete. I have the records of ten cases of this loss of hearing, 
or about one in ten of the total number of cases which have either come 
under my observation, or have been reported to me by physicians in whose 
practice they occurred. One was a young lady, and the others children 
under the age of ten years. Prof. Knapp has examined thirty-one cases. 
" In all," says he, " the deafness was bilateral, and with two exceptions, 
of faint perception of sound, complete. Among the twenty-nine cases of 
total deafness there was only one who seemed to give some evidence of 
hearing afterward." 

One theory attributes the loss of hearing to inflammatory lesions, either 
at the centre of audition within the brain, or in the course of the auditory 
nerves before they enter the auditory foramina. Thus Stille says : k ' This 
symptom appears to depend chiefly upon the pressure of the plastic exuda- 
tion in which the nerves are imbedded. 1 ' The other theory attributes the 



346 CEREBEO-SPINAL FEVER. 

loss of hearing to inflammatory disease of the ear, and especially of the 
labyrinth. Dr. Sanderson, who is an advocate of this latter theory, re- 
marks as follows : " As regards the nature of the affection, there appears to 
he good reason for believing that, like the blindness observed under similar 
-circumstances, and sometimes in the same cases, it is dependent on inflam- 
matory changes in the organ of hearing itself. Br. Klebs was kind 
enough to show me in the pathological museum of the Charite, at Berlin, 
a preparation of the internal ear of a soldier who had died of epidemic 
meningitis complicated with deafness, in which fibrinous adhesions existed 
between the bones of the internal ear and the walls of the vestibule. Dr. 
Klebs stated that in the recent state the mucous lining of the vestibule 
was detached." In the case of a young woman who was deaf from the 
commencement and died on the eighth day, " both tympana were natural, 
but in the left membrana tympani was found a dense white thickening as 
large as a pin's head. On the same side the lining membrane of the 
semicircular canals was distinctly thickened and loosed, and in the ante- 
rior canal there was semifluid purulent masses." Professor Knapp also 
states : " The nature of the ear disease is, in all probability, a purulent 
inflammation of the labyrinth." According to him no disease of the 
middle ear could cause such complete deafness, and, as evidence that the 
deafness is not due to central disease, Dr. Gruening obtained by electri- 
zation the normal reaction of the auditory nerve within the cranium. 
Moreover, if the lesion which destroys hearing be within tbe cranium, why 
is not the function of the other cranial nerves also abolished. Drs. Keller 
and Lucae have also, in three post-mortem examinations, found evidences 
of disease of the labyrinth. 

An argument in support of the former of these theories is the fact, that 
the lesion which produces the deafness is not ordinarily attended by any 
marked subjective symptoms referable to the ear, as otalgia, etc. Again, 
the fact that the deafness is always bilateral and simultaneous in the two 
ears, comports better with the doctrine of a central lesion than with that 
which locates the lesion in the ear. But the true theory can only be posi- 
tively established by dissections, and as we have seen, several post-mortem 
examinations have revealed inflammatory disease of the labyrinth in those 
who have died having this form of deafness, while in no case, so far as I 
am aware, has the ear been found free from inflammatory lesions. There- 
fore, the theory which ascribes the deafness to disease of the ear is much 
better established than the other, and in the present state of our knowl- 
edge we must accept it. Moreover, most of the aurists of this city, who 
have had excellent opportunities to examine these cases, believe in this 
theory. 

Nature. — If w T e examine the literature of cerebro-spinal fevei we will 
find that three theories relating to its nature have been advocated : one 
that it is a local disease, occurring epidemically ; the second, that it is 



NATURE. 347 

akin to typhus fever, or is a form of it ; and the third, that it is a disease 
sui generis. 

The first theory, that it is an epidemic local disease, once had many 
adherents, but it is now nearly discarded. Job Wilson, in 1815, consid- 
ered it a form of influenza, and he conld discern no utility in drawing a 
distinction between spotted fever and influenza. We, in this day, can see 
no resemblance between the two, except that they are both epidemics. 
A more plausible view is, that it is merely an epidemic inflammation of 
the cerebral and spinal meninges. Even Niemeyer says that it presents 
no symptoms except such as are referable to the local affection. But a 
moment's thought will show us that cerebro-spinal fever differs as widely 
from simple meningitis, as scarlet fever with its pharyngitis differs from 
idiopathic pharyngitis. Cerebro-spinal fever begins abruptly, usually in 
those with previous good health ; and its initial symptoms, we have seen, 
are severe ; while sporadic meningitis ordinarily occurs in those of feeble 
or failing health, with an insidious approach, and with gradually increasing- 
symptoms. And though the two diseases have many symptoms in common, 
they differ in others. Scantiness of the urine, dryness of the skin, and 
Tetraction of the abdomen, are observed in sporadic meningitis, while a 
normal or increased amount of urine, a normal or even rounded fulness 
of the abdomen, and often, also, perspiration, are symptoms of cerebro- 
spinal fever. The two diseases differ also strikingly as regards the periods 
of greatest danger and the prognosis ; but the conclusive proof that the 
disease of which we are treating is not a local affection, but constitutional, 
with local manifestations, is found in the fact of a constant and early 
blood change, which in all severe cases is manifested by the appearance 
of the skin, and in other ways. 

Cerebro-spinal fever differs widely in many particulars from typhus, 
although it is probable that it was confounded with it previously to the 
present century, and many even now consider it a form of that disease. 
Their theory is, that from some unknown cause or influence the poison of 
the constitutional disease acquires for the time an affinity for the great 
nervous centres, producing their congestion and inflammation, just as that 
of scarlet fever causes a pharyngitis, and if we could detach from it these 
local manifestations, we would have a malady which differs but little, if at 
all, in its clinical history and nature, from typhus. 

The following are some of the differences which, in my opinion, not 
only establish the non-identity of these two fevers, but show that there is 
no close relationship between them. The causes of typhus are deter- 
mined. Crowding, personal uncleanliness, and imperfect ventilation are 
sufficient to produce it in any season or climate. Such is not the case 
with cerebro-spinal fever. The most that can be said of the agency of 
these and similar anti-hygienic conditions in causing this fever is, as we 
have already stated, that they produce deterioration in the tone of the 



348 CEREBRO-SPINAL FEVER. 

system, so that it is less capable of resisting the prevailing epidemic influ- 
ence. The cause of cerebro-spinal fever occurs independently of the 
usual conditions of life, and is present or operative only at long intervals ; 
else the epidemic would not be so rare. Typhus is highly contagious ; 
cerebro-spinal fever is not contagious, or is feebly so. Typhus is rare 
under the age of ten years, and is most frequent in youth and manhood, 
while the reverse is true of cerebro-spinal fever. Typhus commences with 
mild or moderately severe symptoms, which increase in severity day by 
day, and the period of greatest danger is therefore at an advanced stage 
of the disease. Contrast this with the violence of the initial symptoms of 
cerebro-spinal fever, and the fact that the first and second days are most 
perilous. Moreover, typhus does not seem to be more prevalent during 
epidemics of cerebro-spinal fever than at other times. 

If we pass over those many symptoms due to lesions of the cerebro- 
spinal axis, which are present in cerebro-spinal fever, but are absent in 
typhus fever, there are other points of dissimilarity which cannot be satis- 
factorily explained, except on the supposition of an essential difference in 
the two diseases. The sordes on the teeth and gums, dry and brown fur 
upon the tongue, peculiar mouse-like odor, and more definite duration of 
typhus, are points of contrast with cerebro-spinal fever. Moreover, and 
as, in my mind, very conclusive evidence of the non-identity of typhus 
and cerebro-spinal fever, that common lesion of the former, namely, en- 
largement and softening of the spleen, is seldom present in the latter. 
The spleen has usually been found normal or moderately congested in 
most post-mortem examinations of cerebro-spinal fever. 

Where, therefore, should cerebro-spinal fever be placed in the catalogue 
of diseases ? It resembles scarlet fever in the suddenness and violence of 
its onset ; sporadic meningitis on the one hand, and typhus on the other, 
as we have seen, in many of its symptoms ; influenza and cholera, in the 
infrequency of its visitations, and its epidemic nature. But the particu- 
lars in which it differs from these diseases are more numerous and impor- 
tant than those in which it resembles them. Like a rare object in nature, 
which naturalists are not able to classify with others on account of dis- 
similarities, though it has its resemblances to more than one, cerebro- 
spinal fever appears to stand alone, as a peculiar constitutional disease, 
having a peculiar but obscure cause, and a dangerous manifestation or 
expression located in the cerebro-spinal system. 

Prognosis. — Cerebro-spinal fever is justly one of the most dreaded of 
the epidemic diseases, on account of the great mortality which attends it, 
and the fact that those who survive are often left with some incurable ail- 
ment. The following are the statistics of fifty-two cases, most of which 
occurred in my own practice, and the rest I visited in consultation : twenty- 
six were cured and twenty-six died. Sixteen of the twenty-six who died 
were profoundly and hopelessly comatose within the first seven days, most 



PROGNOSIS. 349 

of them dying within that time, and some even on the first and second 
days, while others lingered into the second week and died without any 
sign of returning consciousness. These statistics therefore show, and the 
same is true of the statistics of other observers, that the first week is the 
time of greatest danger, and if no fatal symptoms are developed during 
this week recovery is probable. Only three deaths occurred after the 
twenty-first day, one from purpura hemorrhagica, the haemorrhages taking 
place from the mucous surfaces, and the other two after a sickness of more 
than two months, in a state of extreme emaciation and prostration. In 
these last cases muscular tremors and convulsions preceded death. The 
ten who subsequently died, but did not become comatose during the first 
week, were nevertheless seriously sick from the first day, but there was hope 
and some expectation of a different issue till near death. 

There is probably no disease which falsifies the predictions of the physi- 
cian more frequently than this. This is due partly to the severity of the 
cerebral symptoms in the commencement, which, did they occur in the 
common forms of meningitis, with which he is more familiar, would justify 
an unfavorable prognosis, and partly to the remissions and exacerbations, 
the occurrence alternately of symptoms of apparent convalescence and 
recrudescence, or relapse, which characterizes the course of this disease. 
Grave initial symptoms, which might seem to have a fatal augury, are 
often followed by such a remission, that all danger seems past, and in a 
few hours later perhaps the symptoms are nearly or quite as grave as at 
first. 

Under the age of five years, and over that of thirty, the prognosis is less 
favorable than between these ages. An abrupt and violent commencement, 
profound stupor, convulsions, active delirium, and great elevation of tem- 
perature are symptoms which should excite solicitude, and render the prog- 
nosis guarded. If the temperature remain above 105° death is probable, 
even with moderate stupor. Numerous and large petechial eruptions show 
a profoundly altered state of the blood, and are therefore a bad prognostic, 
and so is continued albuminuria, since it shows great blood change, or 
nephritis, while other internal organs are probably also involved. In one 
case, a boy, which I had an opportunity of examining nearly a year after 
the attack, the kidneys were still affected. He had anasarca of the face 
and extremities with albuminuria. The renal congestion had apparently 
degenerated into a chronic Bright' s disease. The result of the case I have 
not ascertained. Profound stupor, though a dangerous symptom, is not 
necessarily fatal so long as the patient can be aroused to partial conscious- 
ness, and the pupils are responsive to light; so long as it does not pass 
into actual coma, it is less dangerous than active or maniacal delirium, 
which is apt to eventuate in this coma. 

A mild commencement, with general mildness of symptoms, as the ability 
to comprehend and answer questions, moderate pain and muscular rigidity. 



350 CEREBKO-SPINAL FEVER. 

some appetite, moderate emaciation, little vomiting, etc., justifies a favor- 
able prognosis, but even in such cases it should he guarded till convales- 
cence is fully established. 

Death in the first stages of cerebro-spinal fever appears to occur ordi- 
narily from coma, but we will see from the lesions that congestion of the 
posterior portions of the lungs is frequent, and Sanderson savs : 

" In all the fatal cases which came under my notice, the most prominent 
symptoms, which preceded death, were those which indicate impairment 
and perversion of the respiratory functions. As the breathing became more 
hurried and difficult, the general depression became more intense, the 
pulse became weaker and quicker, and the temperature of the skin more 
elevated." 

He cites the case of a child, who died in that way, but was at the same 
time comatose. In more protracted cases in which there is softening of 
portions of the cerebro-spinal axis, or fibrino-purulent collections around 
it, which are not absorbed, death may occur either from convulsions and 
coma,, or from exhaustion. We have already alluded to one case in which 
purpura hemorrhagica was developed, and the child was exhausted by the 
haemorrhages. 

Those who fully recover often exhibit symptoms usually of a nervous 
character, as irritability of disposition, headache, etc., for months after 
convalescence is established. 

Diagnosis.— Cerebro-spinal fever, on account of the nature and severity 
of its symptoms and the suddenness of its onset, may be mistaken for scar- 
latina, and vice versa. In one instance, to my knowledge, this mistake 
was made. High febrile movement, vomiting, convulsions, and stupor, 
are common in the commencement of scarlet fever, and we have seen that 
the same symptoms ordinarily usher in the severer forms of cerebro- 
spinal fever. It will aid in diagnosis to ascertain whether there be redness of 
the fauces, fortius is present in the commencement of scarlet fever, and in 
a few hours later the characteristic efflorescence appears upon the skin. 

The diagnosis of cerebro-spinal fever from the common forms of menin- 
gitis is ordinarily not difficult, for while in the former there is the maximum- 
intensity of symptoms on the first day, in the latter there is a gradual and 
progressive increase of symptoms from a comparatively mild commence- 
ment. Moreover cases of ordinary or sporadic meningitis occurring at the 
age when cerebro-spinal fever is most frequent, are commonly secondary. 
being due to tubercles, caries of the petrous portion of the temporal bone, 
or other lesion, and there are, therefore, in these cases preceding and 
accompanying symptoms, which are directly referable to the antecedent 
disease. We have seen how different the case is with cerebro-spinal 
fever, which in most patients begins abruptly in a state of previous good 
health. Again in cerebro-spinal fever, after the second or third day, 
hyperesthesia, retraction of the head, and other characteristic symptoms 



ANATOMICAL CHARACTERS. 352 

occur, which are either not present, or are much less pronounced, in 
ordinary meningitis. The symptoms of hysteria sometimes bear a close 
resemblance to the delirium observed in certain cases of cerebro-spinal 
fever. But the thermometer enables us to make the diagnosis, for in 
hysteria there is no febrile movement. In our remarks on the nature of 
cerebro-spinal fever we have sufficiently described the differences between 
this disease and typhus. 

Anatomical Characters. — I have notes of the post-mortem appear- 
ances in 1Q cases, published chiefly in British and American journals ; 29 
died within the first three days ; 28 between the third and twenty-first days ; 
8 died after the twenty-first day, and the duration of the remaining* 11 was- 
unknown. These records furnish the data for the following remarks : 

The blood undergoes changes, which are due in part to the inflamma- 
tory, and in part to the constitutional and asthenic, nature of the disease. 
The proportion of fibrin is increased in cases that are not speedily fatal,, 
as it ordinarily is in idiopathic inflammations. Analyses of the blood,, 
published by Ames, Tourdes, and Maillot, show a variable proportion of 
fibrin from 3.40 to more than six parts in 1000. In sthenic cases accom- 
panied by a pretty general meningitis, cerebral and spinal, there is, after 
the fever has continued some days, the maximum amount of fibrin, while 
in the asthenic and suddenly fatal cases, with inflammation slight, or in 
its commencement, the fibrin is but little increased. The most common 
abnormal appearance of the blood observed at autopsies is a dark color 
with unusual fluidity, and the presence of dark, soft clots. Exceptionally 
bubbles of gas have been observed in the large vessels and the cavities of 
the heart. An unusually dark appearance of the blood, small and soft 
dark clots, and the presence of gas bubbles, when only a few hours have 
elapsed after death, indicate a malignant form of the disease, in which 
this fluid is early and profoundly altered. In certain cases the blood is 
not so changed as to attract attention from its appearance. The points or 
patches of extravasated blood which are observed in the skin during life 
in a certain proportion of cases, usually remain in the cadaver. In incising 
them the Mood is seen to have/ been extravasated, not only in the layers 
of the skin, but also in the subcutaneous connective tissue. Extravasa- 
tions of small extent are also sometimes observed upon the thoracic and 
abdominal organs. 

In those who die after a sickness of a few hours or days, namely, in the 
stage of acute inflammatory congestion, the cranial sinuses are found 
engorged with blood, and containing soft, dark clots. The meninges en- 
veloping the brain are also intensely hyperremic in their entire extent in 
most cadavers ; but in some, in certain parts only, while other portions 
appear nearly normal. In those cases which end fatally within a few 
hours, this hyperemia is ordinarily the only lesion of the meninges ; but 
if the case be more protracted, serum and fibrin are soon exuded from the 



352 CEREBROSPINAL FEVER. 

vessels into the meshes of the pia mater, and underneath this membrane 
over the surface of the brain. Pus-cells also occur mixed with the fibrin, 
sometimes so few as to be discovered only by the microscope, but in other 
-cases in such quantity as to be much in excess of the fibrin, and be readily 
-detected by the naked eye. Pus, which in these cases, no doubt, consists 
of white blood-corpuscles which have escaped with the fibrin from the 
meningeal vessels, sometimes appears early in the disease. Thus, in the 
Dublin Quarterly Journal, 1866, Dr. Gordon relates the history of a case 
In which death occurred after a sickness of five hours, and a purulent- 
appearing greenish exudation had already occurred in places under the 
meninges. The exudation of fibrin commences also in the course of a few 
hours. Thus in a case of thirty hours' duration, published by Dr. William 
Frothingham, in the American Medical Times, April 30th, 1864, and in 
another of one day's duration, published by Dr. Haverty, in the Dublin 
Quarterly Journal for 1867, exudation of fibrin had already occurred in 
and under the pia mater. The arachnoid soon loses its transparency and 
polish, and presents a cloudy appearance over a greater or less extent of 
its surface. This cloudiness is greatest in the vicinity of the fibrinous exu- 
dation, but it occurs also where no such exudation is apparent to the naked 
eye. Dr. Gordon describes a case of only eight hours' duration, in which 
the arachnoid was already opaque at the vertex, but of normal appearance 
at the base of the brain {Dublin Quarterly Journal, 1866), though the 
vessels of the pia mater were everywhere greatly congested. 

The exudation, serous, fibrinous, and purulent, occurs, as in other forms 
of meningitis, within the meshes of the pia mater, and underneath this 
membrane over the surface of the brain. The fibrin is raised from the 
surface of the brain with the meninges. It is most abundant in the inter- 
gyral spaces around the course of the vessels, over and around the optic 
commissure, the pons Varolii, the cerebellum, medulla oblongata, -and 
along the Sylvian fissures. It is most abundant in the depressions, where 
it sometimes has the thickness of y 1 ^- to J of an inch, but it often extends 
over the convolutions so as to conceal them from view. 

Most other forms of meningitis have a local cause, and are therefore 
limited to a small extent of the meninges, as, for example, meningitis from 
tubercles, or caries of the petrous portion of the temporal bone, in both 
of which it is commonly limited to the base of the brain, or from accidents, 
when the meningitis commonly occurs upon the side or summit of the 
brain. The meningitis of cerebro-spinal fever, on the other hand, having a 
general or constitutional cause, occurs with nearly equal frequency upon 
all parts of the meningeal surface, except that it is, perhaps, most severe 
in the depressions where the vascular supply is greatest. In cases of great 
severity, the inflammatory exudation, fibrinous, or purulent, or both, may 
-cover nearly, or quite, the entire surface of the brain. Thus, in the case 
of a negro, 35 years old, only four days sick, whose body was examined at 



ANATOMICAL CHARACTERS. 353 

Bellevue Hospital on May 30th, 1872, the record states that there was a 
purulent exudation over the entire surface of the cerebrum and cerebellum* 
The quantity of serous exudation varies according to the duration and 
amount of congestion. In some the quantity is so small as scarcely to 
attract attention, but in other instances, especially when the disease is pro- 
tracted, it is large. In a case reported by Dr. Moorman in the Amer. 
Journ. of Med. Sci. for Oct. 1866, it is stated that about three pints of 
turbid serum escaped from the cranial cavity in attempting to remove the 
brain, but as there was no measurement the statement may be somewhat 
exaggerated. 

In those who die at an early stage of the disease, the vessels of the brain, 
like those of the meninges, are hyperaernic, so that numerous " puncta vas- 
culosa" appear upon its incised surface. At a later period the hyperaemia, 
like that of the meninges, may disappear. If there be much effusion of 
serum within the ventricles and over the surface of the brain, the convo- 
lutions are apt to be flattened, and the pressure may be such that the 
amount of blood circulating within the brain is reduced below the normal 
quantity. Thus, in the case of a child of three years, who lived sixteen 
days, and was examined after death by Burdon-Sanderson, the ventricles 
contained a large amount of turbid serum, and the brain-substance was 
everywhere pale and anaemic. 

Cerebral ramollissement occurs in certain cases. At one of the examina- 
tions in Charity Hospital, the patient having been only three days sick, 
the brain was found much softened. The dissection was made seven hours 
after death, so that the softening could not have been the result of decom- 
position. At one of the post-mortem examinations in Bellevue Hospital, 
softening of the fornix, corpus callosum, and septum lucidum was observed ; 
and in another, softening in the neighborhood of the subarachnoid space. 
In a case related by Dr. Moorman in the Amer. Journ. of Med. Sci. for 
Oct. 1866, it is stated that portions of the brain, medulla oblongata, and 
pons Varolii were softened. In a case observed by Dr. Upham, softening 
of the superior portion of the left cerebral hemisphere had occurred. 
Occasionally the whole brain is somewhat softened. Burdon-Sanderson, 
Russell, and Githens, each relate such a case. Moreover the walls of the 
lateral ventricles are ordinarily more or less softened in these cases, as 
in the ordinary form of meningitis. In rare instances the brain is 
oedematous, as in a case published by Dr. Hutchinson in the Amer. Journ. 
of Med. Sci. for July, 1866. In this case the patient was only four days 
sick, and the whole brain was oedematous, serum escaping from its 
incised surface. 

The ventricles contain liquid, in some patients transparent serum, in 

others serum turbid, and containing flocculi of fibrin or fibrin with pus. 

The liquid in the different ventricles, as they intercommunicate, is similar. 

The choroid plexus is either injected or it is infiltrated with fibrin and pus. 

23 



354 CEREBKO-SPINAL FEVER. 

In advanced cases with the abatement of the inflammation absorption 
commences. The serum obviously disappears soonest, and the pus and 
fibrin more slowly, by fatty degeneration and liquefaction. Still absorp- 
tion and the return of the brain and meninges to their normal state are 
slow, and hence the .tediousness of convalescence. An infant, whom I 
was allowed to examine in the practice of another physician, took, the dis- 
ease at the age of five months, and two months subsequently, great promi- 
nence of the anterior fontanelle and other symptoms indicated still the 
presence of a considerable amount of effusion within the cranium. No 
post-mortem examinations, so far as I am aware, have yet revealed the 
state of the brain and meninges in those who have had this disease at some 
former period and recovered from it, but it is not improbable that some 
opacity and preternatural adhesions in places may continue for life. 

The remarks made in reference to the cerebral, apply for the most part 
to the spinal meninges. There is at first intense hyperemia of the mem- 
branes usually over the entire surface of the cord, soon followed by fibrin- 
ous, purulent, and serous exudation, in the meshes of the pia mater, and 
underneath this membrane. Thickening and opacity of the meninges, and 
often adhesions, occur in protracted cases. The exudation is sometimes 
confined to a portion of the meninges, more frequently that covering the 
posterior than anterior aspect of the cord, but it may occur in any part, 
and in severe cases the entire pia mater of the spine is infiltrated with it. 
The exudation may have the usual appearance of fibrin and pus, but it is 
sometimes greenish and sometimes bloodstained. Small extravasations 
of blood almost necessarily occur as a result of the intense hyperemia, 
and in one cases related by Burdon-Sanderson it is stated that there was 
a layer of blood one-eighth of an inch thick over the whole cord below the 
bronchial swelling. In post-mortem examinations the central canal of the 
cord has usually been overlooked. Ziemssen relates a case, and Gordon 
another, in which it was dilated and filled with purulent fluid. The ana- 
tomical changes which have been observed in the cord itself have been in- 
jection of its vessels in recent cases, and occasional softening of portions. 
Thus, in a case which was examined in Bellevue Hospital, April 13th, 
1872, it is stated that there w r as softening of the cord in the upper part 
of the dorsal region. In most of the examinations the only abnormal ap- 
pearance observed in the cord was hyperemia, but in a considerable pro- 
portion of cases the records state that the substance of the cord appeared 
normal. 

No constant or uniform lesions occur in the organs of the trunk. The 
most common is congestion of the lungs, especially of the posterior por- 
tions, with more or less oedema, and nodules of hepatization or points of 
extravasation. Effusion of serum, sometimes bloodstained, occasionally 
occurs in the pleural and other serous cavities. The auricles and ventri- 
cles of the heart, as already stated, contain more or less blood, with soft 



TREATMENT. 355 

dark clots in the more malignant and rapidly fatal cases, but larger and 
firmer in those which have been more protracted. The spleen, liver, kid- 
neys, stomach, and intestines, one or more, are sometimes congested, but 
in other cases their appearance is normal. The absence of uniformity as 
regards the state of the spleen, the fact that in many patients it undergoes 
no appreciable change, is important, since this organ is so generally 
enlarged and softened in infectious diseases. The agminate and solitary 
glands have ordinarily been overlooked at post-mortem examinations, but 
in certain cases they have been found prominent. 

Treatment. Preventive. — Although we do not fully understand the 
conditions in which cerebro-spinal fever originates, it is certain, from facts 
observed in epidemics, that we are able to do something to diminish its 
severity and prevalence and to protect community. Measures to this 
end must he of a twofold character, namely, such, in the first place, as are 
calculated to improve the surroundings of the individual, so as to conduce 
to a better state of health, and, secondly, the regulation of his mode of 
life. Cleanliness and dryness of streets and domiciles, perfect drainage 
and sewerage, prompt removal of all refuse matter, avoidance of over- 
crowding, so as to procure the utmost salubrity of the atmosphere, the use 
of plain and wholesome food — in a word, the strict observance of sanitary 
requirements in all the surroundings — cannot fail to reduce the number 
and diminish the severity of cases ; for, as we have seen, this disease as- 
sumes its worst form and numbers the most victims where anti-hygienic 
conditions most abound. Of scarcely less importance is a strict surveil- 
lance of the mode of life, especially of children and young people, during 
the time of an epidemic. We have seen that this disease not infrequently 
follows irregularities in the mode of life, excesses of whatever kind, and 
fatigue, mental or bodily. These should therefore be avoided. A quiet 
mode of life and moderate exercise, plain and wholesome and regular 
meals, and the full amount of sleep, afford some, but not complete, security 
in the midst of an epidemic. 

Curative. — It will aid in determining the proper mode of treatment to 
bear in mind the anatomical characters as ascertained by post-mortem 
examinations. As the chief danger in the first days is from the intense 
inflammatory congestion of the cerebro-spinal axis, the prompt employ- 
ment of measures calculated to relieve this is of the utmost importance. 
To this end bladders or bags of ice should be immediately applied over 
the head and nucha, and constantly retained there during the first week. 
Bran mixed with pounded ice produces a more uniform coldness, and is 
more comfortable to the patient, than ice alone. Cold produces a prompt 
and powerful effect in diminishing the turgescence of the cerebral and 
meningeal vessels. A hot mustard foot-bath or general w y arm bath with 
mustard, should also be employed as early as possible, since it acts so 
powerfully as a derivative from the hypersemic nerve-centres, tends to 



356 CEREBRO- SPINAL FEVEE. 

calm the nervous excitement, and prevent convulsions. An enema to 
open the bowels is also proper. 

Should bloodletting be employed, especially in the more sthenic cases ? 
Even in the commencement of the present century, when it was customary 
to bleed generally or locally in the treatment of inflammatory and febrile 
diseases, a majority of the American practitioners whose writings are ex- 
tant discountenanced the use of such measures in the treatment of this 
disease. Drs. Strong, Foot, and Miner, though under the influence of the 
Broussaian doctrine, were good observers, and they soon abandoned the 
use of the lancet and leeches in the treatment of these patients for more 
sustaining measures. Strong, who published a paper on spotted fever in 
the Medical and Philosophical Register , in 1811, states that certain phy- 
sicians employed venesection as a means of relieving the internal conges- 
tions, but finding that the pulse became more frequent after a moderate 
loss of blood, they soon laid aside the lancet. Some experienced physi- 
cians of that period, however, continued to recommend and practise deple- 
tion, general as well as local, as, for example, Dr. Gallop, who treated 
many cases in Vermont in the epidemic of 1811. 

No physician at the present time recommends venesection, but some of 
the best authorities, as Sanderson and Niemeyer, approve of local bleed- 
ing in certain cases. It may be stated, as a safe rule, that leeches or other 
modes of local depletion should not be prescribed in a large majority of 
cases, and if prescribed in any case it should be on the first day, for on 
the first day the maximum of inflammatory congestion is attained, and in 
no case should more than a very moderate quantity of blood be ab- 
stracted. The abstraction of blood in small quantity, may perhaps be 
permitted in the more sthenic cases, in which, after the prompt employ- 
ment of the other measures recommended, the stupor becomes more and 
more profound, and the patient appears already in incipient coma. But 
in allowing this it must not be forgotten that the disease is in its nature 
asthenic, and in its subsequent course will require sustaining measures. 
It is apparent, however, that the abstraction of blood, if once allowed, is 
likely to be practised too frequently in the treatment of this disease 
by those who have had but little experience with it, for the state of most 
patients in the commencement seems so critical, and the stupor so great, 
that the most energetic measures seem to be required. But if the blood 
of patients be spared, and the;y are promptly and properly treated 
otherwise, it is surprising to see how many emerge from the stupor 
and finally recover. For example, in a case related to me by Dr. 
Griswold, the patient seemed to be comatose for three days, being 
apparently unconscious and the pupils scarcely responding to light, but he 
recovered without losing blood. In only one case have I recommended 
the abstraction of blood, and this was so instructive that I will briefly 
relate it. 



TREATMENT. 357 

M., a female, 4 years old, was seized at 2 a.m., March 7 th, 18/3, with 
vomiting, chilliness, and trembling, followed by severe general clonic con- 
vulsions lasting about fifteen minutes. On visiting her early in the morn- 
ing, I found her semi-comatose, with a pulse of 132, which in a few hours 
rose to 156; temperature 101^°, respiration 44 ; eyes closed; pupils mod- 
erately dilated and responding feebly to light ; surface presenting a dusky 
mottling ; constant tremulousness, and frequent twitching of limbs. Four 
grains of bromide of potassium were ordered to be given every hour to 
two hours, with the usual local measures, namely, ice to the head and 
nucha, and a hot mustard foot-bath, followed by sinapisms to the extremities. 

8th. Pulse 136 ; is partly conscious when aroused, but immediately re- 
lapses into sleep ; head considerably retracted ; bowels constipated ; vomits 
occasionally ; temperature 102°. Treatment, a leech to each temple, on 
account of the extreme stupor ; other treatment to be continued. 

9th. The leech-bites bled, though slowly, nearly five hours ; pulse 180, 
and so feeble as to be counted with difficulty ; temperature 101^°. The 
patient is evidently sinking. Treatment, a teaspoonful of Bourbon whiskey 
in milk every two hours, beef-tea and other nutritious drinks frequently, 
also the bromide at intervals. Evening, pulse 172, still feeble. 

10th. Pulse 180, barely perceptible ; great hyperesthesia ; temperature 
of axilla 100°, of fingers and hand below 90° ; axes of eyes directed 
downward. 

11 th. Pulse still very feeble, varying from 160 to 228 ; temperature 
102£°. There has been no intermission in the use of the stimulants or 
nutriment night or day ; pupils moderately dilated and somewhat more 
sensitive to light. 

After this the patient gradually rallied for a time, so that the pulse 
became stronger and less frequent, but death finally occurred after nine 
weeks in a state of emaciation and extreme exhaustion. Slight convulsions 
occurred in the last hours. 

It is seen that, after the loss of blood from two leech-bites, this patient 
passed into a state of extreme exhaustion, so that for three days I did not 
believe that she would live from one hour to another, and death finally 
occurred. Although the loss of blood may have been useful in relieving 
the stupor, yet a worse danger resulted. Experience like this, which I 
believe corresponds with that of other observers, shows how seldom and 
with what caution the blood of the patient should be abstracted. 

The employment of the bromides is indicated, in ordinary cases, in 
order to diminish the intense cerebral hyperemia, allay the excitement 
of the nervous system, and prevent convulsions. They should be given 
in decided doses as soon as the symptoms indicate the nature of the dis- 
ease. In the New York epidemic, we commonly prescribed the bromide 
of potassium in five or six grain doses, every second hour to a child of 
five years, but more frequently if convulsions occurred or were immi- 
nent. It can be given in frequent and large doses for a few days without 
ill effect ; but its long-continued use, unless there are clear indications 
for it, is to be deprecated, since it produces now and then, when em- 
ployed for many days, symptoms (bromism) which can with difficulty be 
discriminated from those of cerebro-spinal meningitis, such as muscular 



358 CEREBRO-SPINAL FEVER. 

weakness, dilated pupils with perhaps impaired vision, unsteady gait, 
nausea or vomiting, with abdominal pain. Frequent and large doses 
should as a rule be prescribed only in the first week, after which this 
remedy should be discontinued entirely, or given sparingly, but its use 
may be resumed from time to time, during periods of recrudescence, 
which are very apt to occur. 

The intense headache and consequent restlessness which characterize 
many cases require, in addition to the bromide, either the hydrate of 
chloral or an opiate. An opiate is, I think, in most instances preferable, 
and a moderate dose suffices. A patient of six years, in my practice, 
was quieted by one thirty-second of a grain of sulphate of morphia. 

Another remedy scarcely less useful than the bromide is ergot, from its 
known effect in contracting arterioles, and diminishing the arterial 
supply to the cerebro-spinal axis. It can be administered in the tincture, 
fluid extract, or wine. The alkaloid, ergotin, is sometimes employed in 
pill or solution, or given hypodermically in water, with a little glycerine. 
I prescribed a one-grain pill of ergotin to be taken every six hours to a 
child of three years. The efficacy is most marked during the first or 
second week, when the congestion of the nervous centres is greatest. At 
a more advanced stage, when there is less congestion, and the danger 
arises more from the inflammatory products and structural changes, as 
softening, the time for the use of ergot is past, or if still of some service, 
it is less urgently required than at first. 

The similarity of the lesions to those in sporadic meningitis, in the 
treatment of which iodide of potassium is in common use, suggests the 
employment of this agent ; it probably aids in the removal of the liquid 
portion of the exudation. I have prescribed it in combination with the 
bromide, and alone when the bromide was suspended. 

Quinia does not seem to exert any marked controlling effect either 6n 
the course of 'the disease, or the pains, although the severe pains are 
apt to be paroxysmal, so as to indicate the need of this agent as an anti- 
periodic. I have employed it in large and small doses, in one instance 
giving fifteen grains daily to a child of thirteen years, but do not know 
that I have derived any benefit from it, except as a ton ; <\ 

Sustaining measures are indicated from the first. The diet must be 
nutritious during the entire course of the malady, consisting of the ani- 
mal broths, milk, etc. After the violent initial symptoms have abated, 
alcoholic stimulants are needed, and they should be prescribed in all 
cases, however early, in which the pulse is feeble, and there are evidences 
of marked prostration. When the danger from the intense cerebro- 
spinal hypersemia has been averted, tonics, especially the ferruginous, 
may also be employed to aid in arresting the profound blood changes. 
Laxative enemata should be prescribed to relieve constipation, and rectal 
alimentation should be resorted to in those cases in which frequent vomit- 



ACUTE RHEUMATISM. 359 

ing prevents proper nutrition in the natural way. Dry cupping should be 
employed along the spine, two or three times daily, or if for any reason 
the use of the cups be not satisfactory, a stimulating embrocation, as that 
of equal parts of turpentine and camphorated oil, should be prescribed. 
Visitors should be excluded, and the room should be dark and quiet, for 
anything that annoys or excites the patient, whether loud noises or 
talking, or a bright light, or the use of indigestible food, has, in my 
opinion, a tendency to aggravate the malady. 



CHAPTER Y. 

ACUTE RHEUMATISM. 

Rheumatism is a constitutional disease with a local manifestation, 
to wit, inflammation of the sero-fibrous tissues, chiefly in and around 
the articulations, but occasionally in the heart. It was formerly sup- 
posed to be rare in children, but more accurate observations show that it 
is scarcely less common during childhood than in adult life. In young 
patients, especially under the age of six or eight years, it is very apt to 
be overlooked, for the articular inflammations in such patients are com- 
monly slight. In the last ten years, during my connection with the chil- 
dren's class in the Bureau for the Relief of the Out-Door Poor, I have ex- 
amined many children with rheumatism or the cardiac lesions resulting 
from rheumatism, and ordinarily I found that few joints were affected, 
and that there had been but little swelling of them, or redness, and that 
the patients were almost never confined to bed, or even to the sitting 
posture, but had been able to walk about, though with restraint and 
complaint of pain or soreness. The parents in many instances supposed 
that their children were suffering from " growing pains" as they desig- 
nated them. At the same time, with this mildness of symptoms, the 
heart was becoming seriously and permanently crippled, by endocarditis. 
Those who have attended my clinics will recollect that on some days as 
many as three or four children with cardiac lesions have been present 
whose histories showed an overlooked rheumatism of this mild type. 
Cases like the following are very common among the city poor : 

In January, 1871, a little girl, three years old, was presented, having 
distinct aortic direct, and mitral regurgitant murmurs. The mother was 
not aware that she had had rheumatism, but at the age of twenty months 
she had for several days pretty active febrile symptoms, which the physician 
attributed to some other ailment. In April, 1871, another girl, of the 
same age, was brought to the clinic, having a distinct mitral regurgitant 
murmur. The mother stated that she had been well till a month pre- 



360 ACUTE RHEUMATISM. 

viously, when she was confined to her bed for a few days, having a high' 
fever. She was attended by a homoeopathic physician, and the exact 
character of her sickness the mother was not able to state. Further medi- 
cal advice was sought, as the child remained delicate, though her health 
was better than at first. There can be little doubt that the obscure fever 
in this case had been rheumatic. In another child treated elsewhere, not 
old enough to relate the subjective symptoms, there was, in addition to 
an intense fever, evident pain in one foot or leg, when the limb was 
moved. Still, the nature of the disease was not diagnosticated till some 
time after recovery, when a valvular murmur was accidentally discovered. 
Such histories, which I do not think are rare, show that rheumatism may 
occur not very rarely in young children, even infants, for which purpose 
they are here introduced, but they inculcate the important practical lesson, 
that the disease at this age may be so obscure, or latent, as to be over- 
looked even by good diagnosticians. 

Some observers, meeting cases of valvular disease in children, without 
the history of rheumatism, have concluded that rheumatism is not the 
chief cause of endocarditis at this age (Dr. A. Steffen, Jahrbuch fur 
Kinderk., 1870) ; but the explanation which I have given seems to me 
more in consonance with the facts. Scarlet fever not infrequently causes 
endocarditis, but this exanthem is not apt to occur without detection, and 
it has been as often absent as has rheumatism from the histories as given 
by the parents of young children with valvular disease, whom I have 
examined. Moreover, the endocarditis of scarlet fever is in many cases 
associated with, if it do not result from, scarlatinous rheumatism. 

Rheumatism in children is primary or secondary. The secondary form 
occurs chiefly in the declining stage of scarlet fever and variola. It is 
stated, also, to occur occasionally in new-born infants during epidemics of 
puerperal fever, but I have not observed such cases. 

Causes. — An inherited rheumatic diathesis is universally recognized 
as an important predisposing cause of this disease, so that it is apt to 
occur in different members of the same family. When the family his- 
tory shows a strong predisposition to rheumatism, it occurs in the child 
from a slight exciting cause ; if no such predisposition exist, it only occurs- 
through unusual circumstances of exposure. The ordinary exciting cause 
is the same as in most idiopathic inflammations, namely, exposure to cold ;. 
but a strong rheumatic diathesis appears to be sufficient in itself to produce 
an outbreak of the disease. Children who have had one attack are espe- 
cially liable to another. 

The morbific principle in the blood, which produces the phenomena 
and lesions of rheumatism, is supposed to be lactic acid, a theory which 
originated with Prout, and is strengthened rather than weakened by obser- 
vations since his day. According to this theory, lactic acid sustains the 
same causative relation to acute rheumatism as uric acid to gout, and, as 



SYMPTOMS. 361 

Prof. Austin Flint states, it receives support from the fact that the lactic- 
acid treatment of diabetes is apt to produce rheumatic inflammation of 
the joints. 

Symptoms. — The commencement of acute idiopathic rheumatism is in 
most cases sudden ; occasionally fever, and a degree of soreness or stiff- 
ness, precede the articular affection for a few hours or days. The inflam- 
mation, slight at first, increases gradually, attaining its maximum intensity 
within one or two days. The joint is painful, red, hot, and swollen. The 
swelling is due to inflammatory oedema of the tissues surrounding the joint 
and effusion within the joint. As in all inflammations, the vascularity of 
the parts involved is increased, the synovial membrane loses, more or less, 
its lustre, and the effused fluid, which is mainly serum, has been found, in 
most of the cases in which an opportunity was presented to examine it, to 
contain, like the pleuritic exudation, a few globules of pus. Rarely, in a 
reduced state of the system, so much pus is produced within the joint as 
to constitute a true abscess, and rarely also fibrin is exuded, producing a 
rubbing sensation when the joint is moved, and endangering permanent 
adhesion of the articular surfaces. Fortunately, however, in the vast 
majority of cases, the substance exuded both without and within the joint 
is mainly serum, and hence the rapid subsidence of the swelling when 
the inflammation ceases. The pain is commonly not severe when the 
child is quiet, but it is greatly increased if the joint be pressed or the limb 
moved. 

The joints of the extremities are most frequently the seat of rheumatic 
inflammation, but occasionally those of the trunk, as the intervertebral, 
the symphysis pubis, etc., are involved. As the inflammation abates in 
the articulations first affected, it reappears in others, unless the materies 
morbi have been eliminated from the system. It is seldom that more than 
two or three of the joints are in a state of active inflammation at the same 
time. 

The temperature in acute rheumatism is elevated two or three degrees 
above that of health, and the pulse varies from 120 to 140, its frequency 
depending on the age of the patient, as well as the gravity of the disease. 
Perspiration is a common symptom. The appetite is impaired, the tongue 
slightly coated, and the bowels constipated. The watery element in the 
urine is diminished, as in most febrile diseases. There is no corresponding 
reduction in the solid elements, so that the urine is rendered more dense, 
and its specific gravity is high. The amount of urea and coloring matter 
excreted from the kidneys is augmented during the active period of rheu- 
matism, and the urine, when it cools, deposits urates. In ordinary cases 
there is no prominent symptom referable to the nervous system, with the 
exception of pain in the affected joint. 

Acute rheumatism, if only the articulations were involved, would be a. 
disease of little danger, however painful, but unfortunately, in its prone- 



362 ACUTE RHEUMATISM. 

ness to produce specific inflammation of the sero -fibrous tissues, the heart 
frequently becomes involved, less frequently the lungs and pleura, and in 
rare instances the cerebral or spinal meninges. Endocarditis is the most 
frequent of the heart inflammations occurring in rheumatism ; pericarditis, 
though less common, is not infrequent, while in rare instances myocarditis 
occurs, usually associated with the other inflammations. Endocarditis is 
limited to the left side of the heart, and seldom continues long without 
engaging the valves, aortic or mitral, or both, causing their infiltration, 
fibroid degeneration, with consequent thickening, and sometimes adhesion. 
The valvular lesion thus produced is in most instances permanent, so im- 
pairing the action of the valves as to obstruct in greater or less degree the 
flow of blood through the orifice and allow its regurgitation. 

The mitral valve is more frequently affected than the aortic, at least 
bruits produced by this lesion are more frequent in the mitral than 
aortic orifice, and when they are heard in both orifices they are commonly 
loudest in the mitral. This fact, noticed by different observers, I have 
repeatedly verified by observations in this city. 

While the articular affection pertains to the clinical history of rheuma- 
tism, the internal inflammation, whether of the heart, lungs, pleura, or 
meninges, though similar as regards its pathological character, is properly 
considered as a complication. Acute rheumatism is so frequently compli- 
cated by one or the other of these affections, that any disproportionate 
severity in the general symptoms, as compared with the inflammation of 
the joints, or any sudden and unexpected increase in the symptoms, should 
always lead the physician to examine thoroughly the condition of those 
organs which are most frequently affected. 

Inflammatory complications occur, as a rule, during the active period 
of rheumatism, when the inflammation is passing from joint to joint. If 
the general symptoms begin to improve, and no new joints are involved, 
the liability to complications is greatly diminished. Secondary rheuma- 
tism, occurring in most instances in connection with certain eruptive 
fevers, especially scarlatina, commonly affects only a few joints, often only 
one or two, as the wrist, and, though painful, is attended by slight swell- 
ing and redness. 

Duration — Prognosis. — With proper treatment and without compli- 
cation the febrile action in a few days begins to abate, and the disease 
commonly terminates within two weeks. Its duration is ordinarily shorter 
than in rheumatism of the adult. Fluctuations, however, are liable to 
occur. The disease may appear to be abating, and the articular inflam- 
mations nearly cease, when they return for a time, often without new ex- 
posure and without appreciable cause. The prognosis, even when cardiac 
inflammation has supervened, is in most cases favorable, except so far as 
the lesion resulting from this inflammation is concerned, which being 
permanent may entail much subsequent suffering, and occasion death after 



DIAGNOSIS. 



363 



months or years. Indeed, what is most to be dreaded in cases of acute 
rheumatism is valvular disease or pericardial adhesion with its remoter 
consequences, namely, hypertrophy of heart, congestion and oedema of 
the lungs, dropsies, etc. 

Secondary rheumatism occurring in scarlet fever is sometimes also com- 
plicated with, or rather coexists with, cardiac inflammation, pleuritis, or 
pneumonitis, rendering the prognosis more unfavorable. 

In rare instances the acute symptoms of rheumatism abate, but the 
joints remain stiff and more or less swollen, and painful when moved. 
The acute has lapsed into a subacute or chronic rheu- FlG ^q 

matism. Such a case, represented in the accom- 
panying figure, was brought to the children's class 
In the Out-Door Department at Bellevue Hospital, in 
February, 1871. E. H., female, 3^ years old, had 
intermittent fever from the age of nine to fifteen 
months. From this time she remained well till 
the age of two years, when she was taken with acute 
rheumatism, commencing in her ankles and extend- 
ing to other joints. The knee and hip joints on both 
sides have only partially recovered their mobility, 
and both legs and both thighs are permanently flexed, 
so that the gait is slow and unsteady. It is impos- 
sible to straighten either limb without causing great 
pain, and attempts to straighten the thigh produce 
the arch in the back very similar to that in coxalgia. 

Diagnosis. — This is not difficult in ordinary 
cases, if a proper examination be made. In the 
commencement, if the affection of the joints be 
slight, rheumatism might be mistaken for remittent, typhoid, one of the 
eruptive fevers, or meningitis ; but, on careful examination, tenderness 
will be observed of one or more of the articulations, and probably some 
swelling. This tenderness is readily distinguished from the hyperesthesia 
which is common in the first stage of the essential fevers, and which is 
observed when pressure is made upon the chest or abdomen as well as 
upon the limbs, and is more marked between the joints than in them. 
Any doubt which may at first exist, whether the patient may not have 
one of those diseases, is soon dispelled, since their clinical history presents 
notable differences from that of rheumatism. 

I have known scrofulous arthritis, or scrofulous ostitis near the joint, 
present so close a resemblance to acute rheumatism as to be at first mis- 
taken for it. In one instance this inflammation commenced nearly simul- 
taneously in three joints, rendering the diagnosis at first very difficult. 
But scrofulous inflammation, as well as that from pyaemia, can be diagnos- 
ticated from rheumatic disease of the joints, by its greater persistence, less 




364 ACUTE RHEUMATISM. 

induration and symmetry in the swelling, and by the history of the case. 
Chronic rheumatism may produce deformity similar to that from chronic 
scrofulous inflammation, as in the case mentioned above, but the rheu 
matic history, number of joints affected, bilateral character of the inflam- 
mation, good general health, etc., are sufficient to establish a clear diag- 
nosis, when the disease has been observed for some days. 

Treatment. — The theory of the pathology of a disease determines the 
mode of treatment, and the theory that rheumatism is due to an acid in the 
blood, probably lactic, though not established, has been widely received, 
and has led to the extensive employment of alkalies, as tartrate of sodium 
and potassium, acetate of potassium, etc. The alkaline treatment apparently 
materially abridges the duration of acute rheumatism ; but lately a new 
remedy, namely, salicylic acid, has been found to act almost as a specific 
in a large proportion of cases, quickly relieving the pain, and subduing the 
inflammation, so that a few days suffice to effect a cure. Speedy cure of 
this malady is urgently demanded, on account of the imminent peril of 
the heart. Children seem very liable to the cardiac complication. Al- 
though salicylic acid frequently causes the disappearance of all symptoms 
within a week, they are apt to reappear unless the medicine be continued 
in occasional doses for some days subsequently, as I have had opportunity 
to observe. It should be prescribed with an alkali, as in the following 
formula, which is similar to one employed in the Out-Door Department 
at Belle vue : 

IJ . Acid, salicylic, 3 ij — il J ; 

Potas. acetat., 1 ss ; 

Glycerinae, |j ; 

Aqua?, q. s. ad § v. Misce. 
Give one teaspoonful every three hours to a child of six years. 

A new remedy, producing useful therapeutic effects, is apt to be pre- 
scribed at first for too many distinct pathological states, till finally its use 
is restricted to such conditions as it is found to relieve. Salicylic acid 
has undergone this trial, and, while it has been rejected as a remedy for 
the infectious diseases, it is recognized as the most useful of all remedies 
for the disease which we are now considering. An occasional opiate, as 
Dover's powder, may also be needed between the doses of the acid. 

An eligible mode of prescribing salicylic acid is in the salicylate of so- 
dium, which is very soluble and not so unpleasant to the taste as salicylic 
acid in combination with most other bases. It is used more than any 
other preparation of salicylic acid in New York, and much more than any 
other remedy for the treatment of acute rheumatism, and ordinarily with 
a good result. It may be administered in a formula like the following : 
]J. Sodii salicylat., 3ij; 
Syr. bal. tolut., § ij ; 
Aqua?, 1 vj. 
Dose, a dessertspoonful every two or three hours to a child of five years. 



TREATMENT. 365 

During the declining period of rheumatism and in convalescence quinine 
or some preparation of cinchona should be employed and the above medi- 
cine given less often. This tonic does indeed appear to exert a beneficial 
effect on the course of rheumatism, and it is employed by some judicious 
and experienced physicians from the commencement. 

If there be a high temperature and a quick pulse, quinine administered 
in an occasional large dose will be found very useful. Three to five grains 
may be given to a child of five years. 

Rheumatism impoverishes the blood, and the patient often begins to 
present an anaemic appearance, when he requires iron in addition to the 
vegetable tonic. The citrate of iron and quinine may then be employed. 

Secondary rheumatism requires sustaining treatment from the first. 
Such cases ordinarily do well without anti-rheumatic treatment, with the 
general supporting measures employed for the primary disease. 

Pneumonitis complicating rheumatism is best treated by moderate 
counter-irritation and emollient poultices, and the internal use of carbonate 
of ammonium; or, if there be anaemia, carbonate of ammonium with citrate 
of iron and ammonium. The other internal inflammations which are liable 
to arise as complications require iodide of potassium in decided doses. In 
pericarditis or endocarditis, if, as is commonly the case, the movements of 
the heart be accelerated, quinia in large doses, or the tincture or infusion 
of digitalis, is urgently demanded to the extent of reducing the number of 
pulsations to near the normal frequency. A child of six years can take 
three or four drops of the tincture or a large teaspoonful of the infusion, 
to be repeated, if necessary, in three hours, till the required reduction of 
the pulse is effected. Patients often experience relief, by the use of this 
agent, from the palpitation and dyspnoea consequent upon the embarrassed 
movements of the heart. If the heart disease be severe and pulse feeble, 
quinine is also useful. 

The patient should be kept quiet, in a room of uniform temperature, 
and not exposed to draughts of air. By such precaution the danger of 
complications is greatly diminished. Repellent applications, as cold or 
irritants, should not be applied to the joints, as long as the disease is 
acute, for they also increase the danger of complications. The affected 
joints should be enveloped in flannel or cotton, and the pain, if intense, 
may be diminished by applying flannel wrung out of warm water. If the 
disease become subacute or chronic, if the urates have disappeared from 
the urine, and the inflammation cease to pass from joint to joint, the 
tincture of iodine, or moderately stimulating embrocations, applied to the 
joints, involve no danger and are useful. 



im 



ERYSIPELAS. 



CHAPTEE VI. 



ERYSIPELAS. 



The term erysipelas is applied to a constitutional or blood disease, 
which is characterized by inflammation of the skin and subcutaneous con- 
nective tissue, and by a tendency to spread. It is accompanied by 
pungent and pricking heat, swelling, and subcutaneous infiltration. 

In rare instances, in young infants, an inflammation which has been 
designated erysipelas occurs in and around the umbilicus. It commence* 
about the time of the detachment of the umbilical cord, and is accom- 
panied by redness of the skin, tumefaction, and hardness of the connective 
tissue surrounding the umbilicus. It usually causes ulceration of the 
umbilical fossa, and, in fatal cases, pus is sometimes found in the umbilical 
vessels. This disease does not show any tendency to spread ; the diameter 
of the inflamed surface is not more than three or four inches, with the 
umbilicus at the centre. It is generally fatal ; but two favorable cases 
have been reported to me, in one of which there was considerable ulcera- 
tion, and after recovery a firm cicatrix occupied the site of the umbilicus. 
The most reasonable view is that this disease is primarily an inflammation 
of the umbilical fossa and vessels, induced by uncleanliness, cachexia, or 
other cause. It lacks the distinguishing feature of erysipelatous inflam- 
mations, namely, the tendency to spread, and I shall, therefore, take no 
further notice of it in this connection. (See Diseases of the Umbilicus.) 

Erysipelas seldom occurs in childhood ; the few cases which are met in 
this period present nearly the same features, and pursue nearly the same 
course, as in the adult. In infancy, on the other hand, erysipelas is a 
common disease. The following remarks relate to erysipelas occurring 
in this period of life. They are based on data derived mainly from the 
records of cases which occurred in this city, some in my own practice, 
and others in the practice of physicians known to be good observers. 
The points of chief interest in forty-one cases are embraced in the following 
table : 



Oases of Infantile Erysipelas. 



i 


M2 


Age. 


Point of 
commencement 


Parts affected. 


Duration. 


Result. 


l 

2 
3 


M. 
M. 
M. 


5 months. 
2 years. 
10 months. 


Right knee. 
Left knee. 
Elbow. 


Entire surface, except face and 

scalp. 
From a little above the knee to the 

ankle. 
Whole arm and forearm. 


5 weeks and 
3 days. 
7 days. 


Recovered 
Recovered. 
Recovered. 



ERYSIPELAS. 
Cases of Infantile Erysipelas (Continued). 



30T 



Age. 



11 
12 

13 
14 

15 

16 

17 
18 

19 

20 
21 

22 

23 

24 F. 

86 F. 

26 .. 

87 F. 

28 M. 



37 



20 months. 
9 months. 
9 days. 

1 year. 

6 weeks. 

9 months. 

10 months. 

4 weeks. 

3 months. 

4 to 5 mos. 

5 months. 

3 months. 
8 months. 

4 months. 

7 months. 

6 months. 

7 days. 
14 days. 

3 months. 

28 months. 

3 or 4 days. 
314 mos. 

7 months. 
6 months. 

19 months. 

4 months. 

2 months. 

3 to 4 mos 

4 months. 
2 months. 
b% mos. 
2^mos. 

8 months. 

5 months. 



Point of 
commencement 



Below right 

knee. 
Vulva. 

Genitals. 

Vulva. 

At or near the 
ear. 

Epigastric re- 
gion. 

At angle of 

mouth. 
Vulva. 
Vulva. 



5 weeks. 
2 months. 
4 months. 

14 months. 



Vulva. 

From syphilitic 
sores around 
anus. 

Vulva. 

Face near nos- 
trils. 
Vulva. 
Knee. 

Near the ear. 
Left eyelid. 
Genitals. 

Under the chin 

Right shoulder 

Vulva. 
Under left ear. 

Below right 

knee. 
Vulva. 

Near point of 

vaccination. 
Near point of 

vaccination. 
Near vaccine 

vesicle. 
Near vaccine 

vesicle. 
Near vaccine 

vesicle. 
Near vaccine 

vesicle. 
Near point of 

vaccination. 
Near point of 

vaccination. 



Parts affected. 



Near vaccine 

vesicle. 
Left foot. 



Entire leg, thigh, and trunk to the 
umbilicus. 

Abdomen, chest, and all the ex- 
tremities. 

Both lower extremities, abdomen 
to the umbilicus. 

Entire surface, except face. 

Forehead and side of face. 



Trunk and lower extremities. 



Entire face and scalp. 

Entire surface, except face. 
Surface of abdomen to umbilicus 

and right lower extremity. 
All the limbs and trunk, except the 

chest. 
Trunk and both lower extremities. 



Entire trunk and both upper ex 

tremities. 
Eniire trunk and both upper ex 

tremities. 
Entire trunk and all the extremities, 
A portion of trunk and both lower 

extremities. 
Entire face and forehead. 
Left side of face. 
Extended to knees, over abdomen 

to the chest. 
Chin, left cheek, neck, left side of 

trunk, left thigh and leg. 
Arm and forearm. 

Body and all the limbs. 
Neck, chest, and arms. 

Trunk, neck, and head, and all the 

limbs. 
Both thighs, and nearly entire 

trunk. 
Shoulder, arm, and forearm. 



Duration. 



7 days. 
18 days. 
6 days. 

6 weeks. 

1 week. 

2 weeks. 

10 days. 

3 weeks. 
2 weeks. 

3to4weeks 



Result, 



3 weeks. 

About 2 
weeks. 
1 week. 
3 weeks. 

10 days. 

3 days. 

4 days. 



Chest, and both upper limbs. 

Trunk and all the limbs. 

Arm, forearm, and shoulder on one 

side. 
Arm, forearm, and trunk. 

Nearly entire surface. 

Arm and forearm. 

Arm. 



At one ear. 
Left leg. 
Near point of 
vaccination. 
Face. 



Arm and forearm. 

Leg, thigh, and lower part of trunk. 



Entire surface. 

Trunk, and all the limbs. 

Trunk, and all the limbs. 

Trunk, and all the limbs. 



day. 

12 days. 
About 2 
weeks. 

2 weeks. 

3 days. 
21 days. 

2 weeks. 
10 days. 
2to3weeks 

2 months. 

1 week. 



Recovered. 
Recovered. 
Died. 

Recovered* 

Died in 
tetanic 
spasms. 

Died in 
tetanic 
spasms. 

Recovered. 

Died. 
Recovered. 

Died. 



Recovered. 

Recovered. 

Died. 
Recovered. 

Recovered. 

Died. 

Died. 



7 days. 

17 days. 
2 weeks. 



2 weeks. 
2 weeks. 
2 weeks. 

4 weeks. 



Died in con- 
vulsions. 
Died. 
Died. 

Died coma- 
tose. 

Died coma- 
tose. 

Recovered. 

Recovered. 

Died. 

Died. 

Died. 

Died with 
peritonitis. 
Recovered. 

Died, prob- 
ably of 
peritonitis. 
Died. 

Died with 
pneumo- 
nitis. 

Recovered. 

Recovered. 

Died. 

Recovered. 



368 ERYSIPELAS. 

Age. —Of the above cases, 27 were under the age of six months ; 9 from 
six months to twelve, and only 5 above the latter age. A large majority, 
therefore, of cases of infantile erysipelas occur in the first year of life. 

Point of Commencement. — In 58 cases in which I have ascertained 
the point of commencement, it was in 13 cases the vulva, 11 the arm after 
vaccination, 1 the leg, 6 the face, 3 the male genital organs, 3 at or near 
the ear, 1 the elbow, 1 the shoulder, 1 the nates, 1 the foot. In the adult, 
idiopathic erysipelas commonly commences upon the face, and affects only 
the face, ears, forehead, and scalp. On the other hand, in infantile ery- 
sipelas, statistics show that the rash commences upon the face only in a 
small proportion of cases, one in nine, and that it rarely extends to the 
face when it commences in other parts. 

Causes. — In erysipelas the first departure from the healthy state occurs 
in the blood, or the system generally. This undergoes certain changes 
which predispose to erysipelas, or are sufficient in themselves to give rise 
to it. Among the causes, which produce this state of system, uncleanli- 
ness, residence in damp, dark, and crowded apartments, and defective 
alimentation, hold a principal place. Hence this disease is more common 
in the poor quarters of the city than in the country, and in dispensary 
iind hospital than in family practice. 

In a large proportion of cases there is a local exciting cause of the ery- 
sipelatous eruption, namely, an irritation or inflammation at some point, 
generally trivial, but which is sufficient to develop the disease in the sys- 
tem already prepared for it. It is very apt to commence at or near a 
simple ecthymatous or impetiginous eruption, around burns or suppurating 
sores or syphilitic eruptions ; it frequently commences, as is seen by the 
above table, near the point of vaccination immediately after vaccination, 
or when the pock is developed, or again when it has run its course and 
been detached. In a considerable proportion of cases it commences at a 
point where the skin is thin and delicate, or where it unites with a mucous 
surface, probably from some uncleanliness or irritation of those parts. 
Thus, I have records of cases in which it commenced at the external ear, 
commissure of the mouth, and at the vulva. Indeed, the frequency with 
which it commences at the vulva renders female infants more liable to it 
than males. In some instances erysipelas begins without any local ex- 
citing causes, upon smooth and sound skin, even when there are sores 
upon various parts of the surface. 

Vaccination, as an exciting cause of erysipelas, demands particular no- 
tice. Often, doubtless, it is the inflammation which necessarily arises from 
the cut or the vesicle, which operates as an exciting cause of the erysipela- 
tous affection, and not any deleterious property contained in the virus 
which is employed, so that an equal degree of inflammation occurring in 
any other way, as from a burn, would be attended by a like result. But 
facts show that the virus itself occasionally contains a latent noxious prin- 



causes. 369 

•ciple, which, introduced into the system, operates as a cause of erysipelas. 
Thus, a little girl was vaccinated by me in November, 1860, and about 
the time when the vesicle began to fill she was seized with severe inflam- 
mation of the fauces, attended by tumefaction and infiltration of the sub- 
mucous connective tissue. The inflammation rapidly subsided, and within 
a week from its commencement the throat affection had nearly or quite 
disappeared. I now believe that the disease of the fauces was erysipelatous, 
although it was not suspected at the time to have this character. 

As the girl was otherwise healthy, and the vaccine vesicle passed 
through its usual stages, and presented the usual appearance, the scab was 
employed six weeks afterward to vaccinate two infants. Within twenty- 
four hours after vaccination both these infants were seized with high fever, 
ushering in severe erysipelas, commencing in one around the point of vac- 
cination, and in the other around syphilitic sores near the anus. In 
the former case the erysipelatous rash extended from the shoulder over 
the entire limb, and was obstinate, twice reappearing, and extending over 
the same surface ; in the latter (a mulatto child) it extended over both 
lower extremities and a considerable part of the trunk, when the case 
passed into the hands of another physician, and the result is not known. 
The instrument with which the vaccinations were performed was clean. 
The vaccine disease did not appear in either of these cases. 

Again, a well-known physician of this city vaccinated three infants, 
one his own (No. 32 of the table), with part of a scab which had been 
pronounced good, but was taken from a child that he had not seen, and 
with whose state he was not familiar. These infants were all affected 
with erysipelas from the vaccination, his own dying. He had taken the 
precaution to rub the lancet on his boot before using it. Another phy- 
sician of this city has informed me that he vaccinated two children in the 
same family with a scab, with all the precautions that he ever had used, 
and both were soon after affected with erysipelas of a severe form, extend- 
ing from the point of vaccination ; the vaccine disease did not appear. I 
have heard of no case in which the vaccine lymph gave rise to erysipelas, 
and probably it rarely or never does. In the lymph there is no admixture 
of foreign substances, whereas in the scab there is a large proportion of 
animal matter. 

There is a form of erysipelas which occurs in the infant immediately 
after birth, and which is sometimes met in private practice, but is most 
frequently observed as an epidemic in lying-in-wards. It is associated 
with severe, and commonly fatal, puerperal or septic fever, or erysipelas 
of the mother. This form of erysipelas is fatal, almost without exception, 
and its contagiousness is generally admitted by those who have had an 
opportunity to observe cases. 

A case showing the relation of erysipelas in the newly -born infant to 
disease of the mother occurred in the practice of Dr. Learning, of this 
24 



370 ERYSIPELAS. 

city. A woman gave birth to a healthy infant, on the 27th of July, I860. 
A few days subsequently she was seized with a chill, followed by erysipe- 
las, commencing on the thighs, and terminating fatally August 17th. As- 
no autopsy was allowed, the state of the internal organs was not ascer- 
tained. A few days before her death the same disease commenced on the 
infant. It extended around the neck, upon the ears, down the arms, and 
terminated fatally August 24th. But erysipelas in the new-born infant, 
occurring in connection with erysipelas in the mother, is more rare than 
its occurrence with puerperal fever. The records of lying-in asylums fur- 
nish many examples of epidemics of puerperal fever, in which the infants 
of affected mothers perish of erysipelas. 

The late Dr. Folsom, of this city, furnished me the following sketch of 
cases which occurred in his practice and that of his partner : l ' About the 
year 1840, being then in practice in New Bedford, Mass., I was called to 
visit a man who complained of pain in the knee. The next morning he- 
was easier, but the following evening his symptoms grew worse, and as I 
was engaged in a case of obstetrics, my partner, Dr. E. C, now dead, 
visited him. At my call, next morning, I unexpectedly found the patient 
dying. The disease was obscure, and at the autopsy next day no lesion was 
discovered. In making the examination, Dr. C. pricked his finger, and ex- 
periencing little inconvenience from it at first, he attended a case of con- 
finement on the following morning. A few hours subsequently he was 
taken sick, and I took charge of the lady, who died in three days, having the 
tumid abdomen and symptoms of childbed fever. The infant of the patient 
was seized, when two days old, with erysipelas, appearing on the face and 
in spots on the trunk and limbs, and terminating fatally in one day. Dr. 
C.'s finger became swollen and painful, and the lymphatics of the forearm 
and arm became inflamed, presenting red lines, and the axillary glands 
suppurated. Though feverish and much prostrated, there was no appear- 
ance of erysipelas in his case. In about two weeks he resumed practice, 
and as at that time physicians in this country were not fully aware of the 
danger of communicating puerperal fever, he attended two, three, or four 
obstetrical cases each week, until the number reached fifteen. All the 
mothers died with symptoms of metro-peritonitis, and all the infants had 
erysipelas, commencing on the face or some part of the body, generally 
on the second or third day after birth, and in all terminating fatally with- 
in a week. This sad record was finally ended by the doctor's tempo- 
rarily retiring from practice." 

Dr. Condie, in his Treatise on Diseases of Children, says : " Erysipelas 
of infants very commonly occurs during the prevalence of epidemic puer- 
peral fever. Children of mothers who become affected with the fever are 
often born with erysipelatous inflammation ; others are attacked almost 
immediately after birth. Whether, in these cases, the disease is to be 
referred to a morbid matter applied to the skin in the womb, or to the same 



SYMPTOMS. 371 

epidemic or endemic influence which gives rise to the disease of the 
parent, it is difficult to say. According to M. Trousseau, infantile ery- 
sipelas is principally observed when puerperal fever prevails in the wards 
of the lying-in hospitals at Paris." In private practice it is rare that we 
meet erysipelas of the infant associated with erysipelas or with puerperal 
fever in the mother. Some of the oldest physicians of this city, with 
whom I have conversed, and who are engaged in extensive general prac- 
tice, state that they have never met a case in which there was this rela- 
tion. Cases like those observed by Drs. Folsom and Learning only occur 
when epidemic erysipelas or puerperal fever is prevailing. 

Premonitory Symptoms. — Infantile erysipelas in certain cases has no 
premonitory stage, or, if present, it escapes notice. In other instances 
there are well-marked precursory symptoms, as drowsiness, or restlessness, 
febrile movement, oppressed respiration, with perhaps vomiting, and start- 
ing or twitching of the limbs. In Cases 28 and 3*7 of the table, which 
occurred in my practice, the febrile movement, restlessness, and oppressed 
respiration were so great for three days before the appearance of the erup- 
tion, as to cause much anxiety. In the adult, pharyngitis often precedes 
the occurrence of the rash upon the skin. The same inflammation may 
be present in the premonitory period of infantile erysipelas, as well as 
during the period of erysipelatous eruption. The hurried and difficult 
respiration, which is present in the commencement of some cases, is 
probably due to an erysipelatous turgescence of the bronchial mucous 
membrane. 

Symptoms. — The patient with this disease is usually restless, in conse- 
quence of the burning pain which accompanies the eruption. In severe 
cases there is little sleep, night or day, except from medicine. The sleep 
is short, and is often interrupted by sudden starting, or twitching of the 
limbs. Convulsions may occur, but are not common. 

Febrile movement is constant, and is proportionate to the extent and 
gravity of the erysipelas. I have notes of cases in which the pulse was 
more than 200 per minute, although other symptoms did not indicate im- 
mediate danger. The skin not affected by erysipelas is dry and hot, 
though not possessing the pungent heat of the inflamed portion ; face often 
flushed ; tongue moist, and covered with a light fur ; stomach usually re- 
tentive. The state of the bowels varies ; sometimes they are regular, some- 
times variable, while in other cases the stools are green, and more 
frequent than natural. I have records relating to the state of the bowels 
in twenty cases, as follows : in seven, regular ; in nine, loose ; in two, 
constipated ; in one, constipated, then loose ; and in one, constipated, 
then regular. Diarrhoea, when present, is usually mild, requiring little or 
no treatment. The erysipelatous redness is not in all cases so pronounced 
as in the adult, but otherwise there is nothing peculiar in its appearance. 
In feeble infants, with an impoverished state of the blood, its color is pink. 



372 EKYSIPELAS. 

instead of the deep red which characterizes the inflammation in the robust. 
Points of vesication may occur where the inflammation is most severe, as 
in the adult, and subsequently the same desquamation and cedema. 

If the infant be debilitated, there is great danger of the formation of 
abscesses, around which the inflammation lingers after it has disappeared 
from every other part of the body. Sometimes also, in very young infants 
gangrene occurs, especially in the genital organs in the male. Several of 
these cases have been related to me, all under the age of a month or six 
weeks, and all fatal. Occasionally the sloughing is so great as to denude 
the testicles. A noteworthy feature of erysipelas in infants is its prone- 
ness to return. When it has been progressively subsiding, and hope is 
entertained of its speedy disappearance, it not infrequently is suddenly 
relighted from some unknown cause, travelling again over the same, or 
parts of the same, surface. In one case the disease, arising from vaccina- 
tion, extended three times over the arm and forearm ; and in another 
case, a second time over both legs and a considerable part of the trunk. 

The internal inflammations, which most frequently complicate erysipe- 
las, and give rise to symptoms which are superadded to those pertaining 
to the erysipelas, are pharyngitis and peritonitis ; and more rarely broncho- 
pneumonia or enteritis. In a case which I examined after death, in the 
Nursery and Child's Hospital, and in which, the erysipelatous inflamma- 
tion having extended over the abdomen, the lesions of peritonitis were 
present, it seemed probable, from the thinness of the abdominal walls, that 
the inflammation had extended through the parietes from the external to 
the internal surface. 

Prognosis. — Erysipelas is much more fatal in infancy than in adult 
life. In the death statistics of this city for three years, I find eighty 
deaths from erysipelas of infants under the age of one year, to eighty- 
three deaths from this disease above that age. Age greatly influences the 
prognosis. Infants under the age of three weeks usually die ; from the 
age of three weeks to six months the result is doubtful ; while above the 
age of six months a majority recover with correct treatment. It will be 
seen by the foregoing table that seven infants under the age of six weeks 
had erysipelas, and six died ; from the age of six weeks to six months, six 
recovered and nine died ; and above the age of six months, nine recovered 
and four died. 

With the exception of a case of the so-called umbilical erysipelas, the 
youngest child who recovered, of whom I have obtained information, was 
three weeks old. In this case the rash extended nearly over the entire 
surface, beginning with the face. Case 38 of the table, treated by my- 
self, was very similar as regards the extent of the erysipelatous eruption 
and the result. This infant was five weeks old. 

It is scarcely necessary to state that erysipelas is more favorable when 
it affects the limbs than when it invades the head, neck, or body ; when it 



PATHOLOGICAL ANATOMY. 373 

spreads slowly than rapidly ; when it is superficial than when phlegmonous. 
In those cases in which the connective tissue is much involved, the infant 
is not always safe after the disease has run its course ; he sometimes dies ex- 
hausted from the discharge of abscesses ; I have records of two such cases. 

Duration. — In sixteen cases that recovered, the erysipelas terminated 
within the first week in two, the second week in six, the third week in five, 
fourth week in one, and in two cases it lasted five and six weeks. The 
average duration was fifteen days. In nineteen fatal cases, ten died within 
the first week, five the second w r eek, three the third week, and one in the 
fourth week. The average duration of fatal cases w r as about ten days. 

Modes of Death. — Death occurs in different ways ; in clonic or tonic 
convulsions followed by coma, from exhaustion, and from internal innarn- 
mation ; that from exhaustion being probably the most common. 

Pathological Anatomy. — The blood doubtless in this disease under- 
goes certain pathological alterations previously to the occurrence of the 
eruption, but the exact changes are not known. Onr knowledge of the 
morbid anatomy of erysipelas relates chiefly to the local affections, which, 
with the exception of the inflammation of the skin, are not constant, and 
may, therefore, be regarded as complications. The cutaneous inflamma- 
tion affects all the structures of the skin, and in greater or less degree also 
the subcutaneous connective tissue. The inflammation is accompanied by 
more or less serous effusion or oedema. 

The not infrequent occurrence of peritonitis in connection with erysipelas 
has long been known. In Heberd en's Epitome Morborum Puerilium, the 
anatomical character of erysipelas is expressed in one sentence : " When 
the body has been opened after death, the intestines have been found glued 
together and covered with coagulablc lymph." Since Heberden's time, 
nearly all who have written on diseases of infancy and childhood have 
mentioned peritonitis as one of the most common complications. Under- 
wood says : " Upon examining several bodies after death, the contents of 
the body have frequently been found glued together and their surface cov- 
ered with inflammatory exudation, exactly similar to that of women who 
have died of puerperal fever." Similar remarks in reference to the fre- 
quency of peritonitis in this disease are made by recent writers. 

The statistics in reference to erysipelas as well as peritonitis show that 
in infants in hospital practice, and in those affected by erysipelas during 
epidemics of puerperal fever, peritonitis is a not infrequent complication. 
On the other hand, as we commonly meet cases of infantile erysipelas oc- 
curring sporadically in private practice, there are not sufficient abdominal 
distension and tenderness to indicate peritonitis. In only one of the cases 
embraced in the foregoing table was a post-mortem examination made, and 
in that there had been no peritonitis. The occurrence of pharyngitis in 
connection with erysipelas has been already mentioned. 

Enteritis has been alluded to as another complication in infants. Diar- 



374 EKYSIPELAS. 

rlioea has been stated to be a symptom in certain cases ; it has been found 
to be dependent on enteritis of a mild grade. Billard made post-mortem 
examinations of sixteen infants who died of erysipelas, and " found in 
two gastro-enteritis, in ten enteritis, in three pneumonia complicated with 
enteritis and cerebral congestion, and in one pleuro-pneumonia. " 

Treatment. — On this side of the Atlantic great uniformity prevails as 
regards the treatment of erysipelas. Sustaining measures are prescribed, 
and the tincture of the chloride of iron is the tonic generally preferred. 
Whatever the intensity of the febrile reaction and the stage of the disease, 
if there be no intestinal complication, ferruginous or other tonics should be 
administered. The largest doses of the tincture of the chloride of iron 
given in any of the cases in the above table were in case No. 4, namely, 
ten drops every two hours, and this patient recovered in seven days from 
a pretty severe attack. Probably, however, nothing is gained by such 
large doses, and they may irritate the intestinal surface, and increase the 
liability to enteritis, which, we have seen, complicates a certain proportion 
of cases. Four drops may be given every three hours to a child from one 
to two years of age. Instead of the iron, or in addition to it, one of the 
preparations of cinchona may be prescribed. Beef-tea, and wine-whey 
or other alcoholic stimulant, are required. 

The depressing measures recommended by certain writers cannot be too 
strongly censured. One author says : ' ' We should endeavor from the first 
to allay the inflammation of the skin by energetic treatment. . . . Local 
abstraction of blood, by means of one or two leeches applied at the cir- 
cumference of the primary seat of the erysipelas, should be put in force, 
provided the power of the constitution of the children permits. " Such 
treatment may explain one of this author's aphorisms, namely, the erysipe- 
las of infants is a fatal disease. 

Local treatment may be employed to arrest the extension of the inflam- 
mation, but the result in most cases is not encouraging. Solid nitrate of 
silver was employed in two cases, of w 7 hich I have records, and in both 
the result was pernicious. Troublesome sores were produced, from which 
blood escaped, and in one of the cases, at least, death was attributed by 
the parents to this treatment, rather than to the disease. 

Tincture of iodine is a better remedy for arresting the extension of ery- 
sipelas. It should be applied from the margin of the inflammation, over 
the sound skin, to the distance of about two inches. It may be ineffectual, 
but it does not produce any unfavorable result. Soothing applications, 
like rye flour, or a lotion of sugar of lead, may be made to the inflamed 
surface, as in erysipelas of the adult. I prefer, however, for local treat- 
ment, the constant application of vaseline or glycerine and water, to which 
a few drops of carbolic acid are added. 



PART III. 



SECTION I. 

DISEASES OF THE CEREBRO- SPIN AL SYSTEM. 

Diseases of the brain and spinal cord are less frequent than those of 
the respiratory and digestive systems. They are also less amenable to 
treatment, and are much more fatal. They largely increase the aggre- 
gate of deaths. They contrast with the diseases of the other systems in 
their greater relative frequency in infancy and childhood than in adult 
life. This is explained, as regards the brain, by the rapid development 
and active molecular change in this organ in early life, its great impressi- 
bility by the emotions, and the thinness of the covering which protects it 
from external agencies. 

Some of the most interesting of the cerebro-spinal diseases which are 
to engage our attention, are peculiar to early life, as tetanus infantum. 
The diseases of this system also contrast with other local affections in their 
greater obscurity, especially in their commencement ; for, while maladies 
of the thorax can be readily ascertained by auscultation and percussion, 
or those of the abdomen by the nature of the evacuations or the degree of 
tenderness or distension, our means of conducting examination through 
the bony encasement of the cerebro-spinal axis are meagre and unsatisfac- 
tory. The condition of the brain and spinal cord must be determined, 
chiefly, by the study of symptoms, and not by direct examination. The 
condition of the anterior fontanelle in young infants, however, enables us 
to determine the presence or absence of active congestion of the brain. 
If there be an excess of arterial blood, it is convex. Prominence of the 
fontanelle is common in inflammatory and febrile diseases, and is a sign 
of considerable diagnostic and prognostic value. 

Within a few years, the ophthalmoscope has been employed as a means 
of diagnosis in cerebral diseases, and although the employment of this 
instrument for such purpose is but recent, enough has been elicited to 
prove its value as an aid in determining the state of the brain. Prof. H. 
D. Noyes remarks on this subject :...." The argument for making 
ophthalmoscopic examination in all cases of brain disease, becomes irre- 
sistible. Indeed, a moment's reflection would lead to this conclusion with- 
out any considerations drawn from pathology. The optic nerve is only an 



376 DISEASES OF THE CEEEBRO-SPINAL SYSTEM. 

outlying portion of the brain ; its extremity is fully exposed to view. Sit- 
uated within about two inches of the brain, it is the only nerve in the 
body which we can inspect ; it contains bloodvessels which communicate 
directly with the intracranial circulation. We thus come into relation 
with the cerebrum, by continuity of nerve-structure and also of blood- 
vessels. ' ' 

Structural changes in the optic nerve and retina have been discovered 
by means of the ophthalmoscope in meningitis, hydrocephalus, phlebitis 
of the sinuses, apoplexy, etc. Among the lesions which have been ob- 
served by this instrument, are hyperemia, more or less opacity and tume- 
faction of the optic nerve, engorgement of the vessels of the retina, with 
serous or sero -fibrinous exudation and ecchymotic points. In certain pro- 
tracted diseases, as chronic hydrocephalus, in which dimness or loss of 
sight occurs, the ophthalmoscope discloses a state of atrophy of the optic 
nerve. Heretofore this instrument has been chiefly employed by ocu- 
lists, but as it comes into more general use, there can be little doubt that 
it will be recognized as an important aid in the diagnosis of obscure cere- 
bral diseases. 

Still, with all possible aids to diagnosis, the obscurity which attends the 
invasion of many of the cerebro-spinal diseases must be acknowledged. 
To the hasty and careless physician, their symptoms are often deceptive. 
Careful weighing of the phenomena, and thorough and protracted exam- 
ination, are requisite in order to insure correct diagnosis and proper treat- 
ment. Some of the cerebro-spinal affections are, in reality, sequelae of 
other diseases, as, for example, spurious hydrocephalus ; and some are,. 
strictly speaking, only symptoms, as convulsions ; but, on account of their 
importance, and because they require special treatment, it is proper to 
consider them as diseases per se. 

The brain presents certain peculiarities in infancy and childhood. In. 
the foetus, while the other organs are well formed, the brain, especially 
its cerebral portion, is still diffluent, and at birth it has so little consis- 
tence that it must be handled carefully to prevent laceration. This soft- 
ness is due to the large proportion of water which it contains. The follow- 
ing analyses show the composition of the brain in three periods of life : 



Infant. 


Youth. 


Adult. 


7.00 


10.20 


9.40 


3.45 


5.30 


6.10 


.80 


1.65 


1.80 


5.96 


8.59 


10.19 


82.79 


74.26 


72.51 



Albumen, 

Cerebral fats, 

Phosphorus, .... 

Osmazome, salts, . 

Water, 

At birth the brain has a nearly uniform white color. The gray sub- 
stance, in which the nervous power originates, is undeveloped. The date 
of its appearance corresponds with the first exhibition of emotion or intel- 



ACEPHALUS — ANENCEPHALUS. 37T 

ligence, and the decided gray color which we observe in the brain of the 
adult does not appear until the age of full mental activity. 

In the new-born the brain is large in proportion to the rest of the body, 
and its growth during infancy and childhood is rapid. Until the fifth, 
year, as appears from the observations of Dr. Peacock, its weight is about 
one-seventh or one-eighth that of the entire system, the proportions vary- 
ing somewhat in different cases. 

The brain does not attain its full size, as stated by Dr. West, at the age 
of seven years, but, according to Dr. Peacock's statistics, it continues to- 
increase till the age of twenty-five or thirty, although its growth is less- 
rapid after the age of seven years than previously. 

The membranous covering of the cerebro- spinal axis is scarcely less 
interesting to the pathologist than the axis itself. I shall speak in tho 
following pages of the arachnoid and cavity of the arachnoid, for conve- 
nience of description, although aware of the fact that some eminent 
authorities, as Virchow and Kolliker, whose opinions in reference to the 
minute anatomy of the system always command attention, if not assent,, 
believe that there is no arachnoid, but what has heretofore been called by 
this name is on the one side the smooth surface of the dura mater and on 
the other of the pia mater. 

The dura mater is seldom involved in the diseases of early life, except 
as it is affected by pressure, while the pia mater and arachnoid are the 
seat and source of some of the most important diseases, as meningitis, 
meningeal apoplexy, etc. 

The more complicated and delicate the structure of an organ, the more 
liable it is to errors of nutrition and growth. There is, therefore, no organ 
which is so liable to irregular development as the brain. It may be en- 
tirely wanting ; or it may be partially developed, certain portions being 
absent ; or, lastly, its growth may be excessive, constituting an hyper- 
trophy. 



CHAPTER I. 

ACEPHALUS— ANENCEPHALUS. 

Entire absence of the encephalon is not common, but there are many 
cases of this monstrosity on record. In extreme cases the head and part 
of the neck, as well as the brain and medulla oblongata, are absent. 
When there is great deficiency there is often a twin, the presence of which 
has interfered with the full development of the foetus. Sometimes the 
growth of other organs besides the brain is imperfect. 

Anatomical Character. — In the ordinary form of anencephalus the 
brain and sometimes the medulla are absent, with the absence or imper- 



378 



SYMPTOMS — PROGNOSIS. 




feet development of their membranous and osseous covering. The vault 
of the cranium is absent. There is deficiency of the frontal, parietal, 
and occipital bones, except those portions which are near the base of the 
cranium. These portions are very thick and closely united, as if there 
were the usual amount of osseous substance, but instead of expanding into 
the arch, it had collected in an irregular mass at the base of the cranium. 
The absence of the brain and the cranial arch gives a remarkable ap- 
pearance. The eyes are prominent, the neck thick and short, while the 
l)ody and limbs are ordinarily well developed. The physiognomy has 
p IG i7 been compared to that of some of the 

lower animals. 

The base of the cranium is often oc- 
cupied by a vascular tumor, not large, but 
of different size in different cases, and 
continuous below with the spinal pia 
mater. This vascular tumor is the rep- 
resentative of the cranial pia mater, and 
its smooth surface is the analogue of the 
arachnoid. The dura mater and the 
scalp being absent, the exposed mass 
resembles very much in appearance, as it 
does in structure, the placenta, and the sensation which it imparts to the 
finger pressed upon it is very similar. Sometimes small portions of cere- 
bral matter are found among the vessels of this tumor, but they are so 
■disconnected or isolated that they do not perform, in any way, the func- 
tion of a brain. Occasionally the vascular tumor is absent, and the 
medulla or upper extremity of the spine is exposed, or it terminates in a 
little papilla at the back of the neck. 

Those portions of the cranial nerves which lie external to the cranium 
are well developed, although the intracranial parts may be absent. 

Symptoms. — The respiration in anencephalous monsters is irregular. 
They can be made to cry, but their cry is a sort of sob or hiccough, and 
occasionally they even nurse. The digestive function is well performed, 
and regular urinary and fcecal evacuations occur. There is a tendency in 
anencephalous monsters to convulsions. Blowing upon them, and pressure 
upon the projecting medulla, if this be present, frequently produce this 
effect. 

Prognosis. — Fortunately these monsters are short-lived. If the medulla 
oblongata, which is essential to the maintenance of respiration, be absent, 
extra-uterine life is impossible. Stillbirth is the result. If the medulla 
oblongata be present, although respiration and circulation are established, 
death commonly takes place within two or three days, and almost always 
within the first week. Convulsions sooner or later occur, ending in fatal 
coma. 



IMPERFECT BRAIN. 379 



CHAPTEE II. 

IMPERFECT BRAIN. 

Between the absent and complete brain there are various grades of de- 
ficiency. Parts of the brain may be perfect, while other portions are either 
absent or imperfectly formed. The deficiency is usually in the superior 
parts of the brain, especially in the hemispheres of the cerebrum, while 
the base of the organ is perfect. Both hemispheres may be absent, or one 
may be absent, while the other hemisphere is shrivelled or rudimentary. 
Occasionally the cranium preserves its normal shape and size, in conse- 
quence of an increase in the cerebro-spinal fluid proportionate to the lack 
of brain-substance. The imperfect development is not then apparent to 
the observer. The rudimentary hemispheres in these cases are spread out, 
forming the walls of a sac inclosing the liquid. The post-mortem exami- 
nation of the following case was made in the Nursery and Child's Hospi- 
tal, of this city, in 1862. 

Case. — Female ; parentage healthy ; she was plump and well formed at 
birth, and nothing unusual was observed in her condition, as she nursed 
and throve like other children, till she reached the age when there is, 
usually, the first manifestation of intelligence. With her there was no 
evidence of any intellect, or, if any, it was very indistinct. She nursed, or 
took food when placed in her mouth, but apparently without relish, as if 
instinctively. She never reached her hands toward the nurse, or toward 
playthings. So indifferent and apparently unconscious was she of objects 
around her, that it was thought for some time that she was blind. She 
never smiled, except when her hands were gently rubbed or shaken ; and 
then the smile seemed to be a movement more reflex than emotional. The 
smile was immediately succeeded by a fixed vacant look. She usually lay 
quietly, with her arms crossed ; and during the last month of her life she 
sometimes uttered a scream, like children with cerebral diseases. Her 
evacuations were regular, and she was not subject to vomiting, before she 
was attacked with the acute disease of which she died. The size of her 
head was rather less than usual at her age, but not less than is often seen 
in well-formed children. The forehead was small in proportion to the rest 
of the head, but the difference was not such as to attract attention. For- 
tunately, the existence of this idiot was terminated by an attack of entero- 
colitis at the age of about ten months. 

Sectio Cadav. — The head was measured, but the measurements were 
lost. They did not seem to differ materially from the normal standard. 
The sutures were united, and the fontanelles nearly, if not quite, closed. 
The frontal bone lay a little lower than the plane of the parietal. The 
meninges of the brain presented nearly their normal appearance, but were 
distended with transparent serum. The quantity of fluid was estimated 
at about two-thirds of a pint, and when it was evacuated, the floor of the 



380 IMPERFECT BRAIN. 

lateral ventricles was brought into view. There was almost an entire ab- 
sence of that part of the brain which lies above the floor of the ventricles. 
On close inspection, rudimentary cerebral hemispheres were found in a 
thin layer forming a part of the walls of the sac. The whole amount of 
brain-substance above the ventricle did not exceed the size of a small egg. 
The cerebellum, the base of the brain, and cranial nerves presented their 
usual appearance. The entire brain, after being a few days in diluted 
alcohol, weighed six and a quarter ounces. 

In this case, the fluid was only sufficient to compensate for the deficiency 
of the brain. In other, and probably the larger number of cases of in- 
complete brain, the cerebro-spinal fluid is not materially increased. There 
is then but slight elevation of the frontal bone, the forehead is low, or re- 
treating, or even almost absent. This is that shape of head which is uni- 
versally regarded as characteristic of idiocy. 

Symptoms. — The symptoms in cases of deficient brain relate to the 
mind. If the cerebral hemispheres are absent, there is no intelligence. 
The individual, as regards mental endowments, does not rise above the 
instincts of the lower animals. If the hemispheres are partially developed, 
there is a degree of intelligence proportionate to the amount of cerebral 
substance present. If the deficiency be confined to one side, there is no 
apparent lack of intelligence or mental capacity, since, the brain being a 
double organ, one side performs the function of both. 

Prognosis. — The prognosis as regards life, in cases of imperfect brain,, 
depends not so much on the amount of deficiency as the exact seat of ar- 
rested growth. If only the cerebrum be partially, or even entirely absent, 
the infant may live and thrive. But if those portions lying at the base of 
the brain, which control the functions of animal life, are lacking, or are 
imperfectly formed, life is very uncertain, and probably short. 

It is evident that no therapeutic treatment can remedy a congenital de- 
ficiency. The services of the physician are not required. The philan- 
thropic and patient teacher may impart a degree of intelligence to the 
idiotic, and the instruction of these unfortunates has of late years been 
successful. 

Microcephalus — Atrophy of Brain. 

An abnormally small brain has usually been attributed to premature 
closure of the sutures and fontanelles by too rapid ossification. But in 
certain cases which I have met there was no evidence of exaggerated os- 
sification, and the fault seemed to me to be a deficiency in the growth of 
the brain, while the ossifying process was not exaggerated or was even 
less than normal. A normal development of the cranial bones, with but 
little brain -substance to keep them apart, would necessitate early oblitera- 
tion of sutures and fontanelles. Thus in August, 1878, an infant was 
brought into the Bureau for the Relief of the Out-Door Poor, with marked 



MICROCEPHALIA — ATROPHY OF BRAIN. 381 

microcephalism. Its age was 19 months, and the bone formation was so 
slow that only two teeth had appeared ; the circumference of its head 
was 14^- inches ; it had had repeated convulsions since the age of five 
months, and the mother stated that its head had been round and hard from 
its birth. In microcephalus, death, sooner or later, is the common re- 
sults ; life ends in convulsions and coma. 

Again, the brain of the child, when undergoing development, with the 
cranial bones sufficiently yielding, may not only cease to grow, but may 
even diminish in size, in consequence of protracted and exhausting diseases. 
Diminution in the size of the brain occurs especially after fevers and diar- 
rheal affections of long standing and attended with much emaciation. 
The waste of the brain corresponds with the general loss of flesh. If the 
cranial sutures be not united, the occipital and sometimes the frontal 
bones are depressed, according to the diminished size of the brain, and are 
overlaid by the parietal. In foundlings of two or three months, this loss 
of brain-substance is often very striking. In infants of this class who have 
died of protracted diarrhoea, it is not unusual to observe the occipital 
bone not only depressed, but extending one, two, or even three lines un- 
derneath the parietal. 

If the child with shrunken brain, from protracted and exhaustive dis- 
ease, be old enough to express its thoughts, it often seems foolish, talks but 
little, and perhaps says the same thing over and over again. In one case 
in my practice, a little girl, having passed through a long course of typhus, 
persistently repeated during her convalescence, with a silly smile, the ques- 
tions addressed to her. This peculiarity continued two or three weeks, 
although her appetite was good, and her restoration to health rapid. In 
another case a little boy, during convalescence, was wont to laugh heartily 
at the appearance of the ordinary articles of furniture in the room. Both 
showed more impairment of mind during convalescence than in the midst 
of the fever. The friends of such children are in a state of great anxiety 
lest their minds be permanently enfeebled, but, as the appetite and 
strength return, the nutrition of the brain is re-established, and the mind 
regains its former vigor. In cases of wasted brain, with cranial bones 
united, the deficiency is supplied by serous effusion, which is gradually 
absorbed as the health of the patient is re-established, and the brain en- 
larges. This effusion occurs not only over the convexity of the brain, but 
also at its base, and sometimes in the ventricles. Dr. West states that in 
atrophy of the brain, from protracted disease, its texture is firmer than 
usual. I have not noticed this in infants, but my attention has not been 
directed particularly to this point. It is probable that there is some 
change in the anatomical character of the brain, aside from mere waste. 

Partial atrophy of the brain sometimes, also, occurs from primary dis- 
ease located in this organ ; the affected portion wastes, while the rest re- 
tains its normal development. 



382 HYPERTROPHY OF BRAIN. 



CHAPTER III. 

HYPERTROPHY OF BRAIN. 

In contrast with atrophy of the brain is the opposite state, or hyper- 
trophy. The size of this organ within the limits of health varies greatly 
in different individuals, but sometimes there is so great an increase in vol- 
ume as properly to constitute a disease. Fortunately hypertrophy of 
brain is rare in America. 

Pathological Anatomy. — The excess of growth which cnaracterizes 
this disease has been ascertained to be confined to the white portion of the 
brain, and ordinarily to that part contained in the cerebral hemispheres. 
Hypertrophy of the brain is attended by induration, which exists in differ- 
ent degrees in different cases. It is in some so slight as to be scarcely 
appreciable ; while in others it is apparent at once by pressure with the 
finger, or incision with the scalpel. Rilliet and Barthez state that the in- 
duration in some cases resembles in degree and appearance that produced 
by the action of alcohol. The white substance of the cerebrum is not 
only resisting and elastic, but its color is unusually pale ; it presents even 
a brilliant or polished appearance. At the same time the gray substance 
is more or less faded, and its depth in the convolutions is less than in the 
normal state of the organ. Rokitansky says : " The cineritious matter is 
generally of a pale grayish-red color. The medullary is always dazzling 
white, and remarkably pale and anaemic." An unusual case is related by 
Burnet, in which the gray substance in the corpora striata retained its 
usual color, and was indurated like the white substance. In exceptional in- 
stances the cerebellum as well as cerebrum undergoes hypertrophy, becom- 
ing at the same time more or less indurated. In Burnet's case there was 
induration of the optic nerves. " The internal structure," he says, " of the 
optic nerves, especially in their bulbs, had the polish, homogeneous appear- 
ance, elasticity, and almost the hardness of cartilage." Rilliet and Bar- 
thez state that in two cases the spinal cord presented even more marked 
induration than the encephalon. Congestion is not a feature of hypertro- 
phy. On the other hand, there is often less vascularity of the brain and 
its membranes than in the healthy state. If the cranial bones be com- 
pletely ossified at the time when hypertrophy commences, and firmly 
united, enlargement of the brain is partially prevented. The convolu- 
tions are then thin, much flattened, the sulci more or less effaced, the 
membranes pale and dry, and the ventricles are small and nearly desti- 
tute of serum. At the autopsy of such a case, when the dura mater is in- 
cised, the expansion of the brain prevents the proper refitting of the skull- 



CAUSES. 38S 

cap. Occasionally hypertrophy causes more or less absorption of the 
cranium, and perhaps the sutures already united are pressed apart. 

If hypertrophy commence in young infants with the fontanelles and 
sutures still open, they usually remain open, or are a long time in uniting. 
The interspaces continue, not only in consequence of the growth of the 
brain, which tends to separate the bones, but also in consequence of feeble 
ossification. The shape of the head arrests attention. Hypertrophy usu- 
ally produces most enlargement between and above the ears, while the 
frontal portion of the head, though somewhat enlarged, is less developed. 

The direction of the eyes is not changed, as is common in congenital 
hydrocephalus. 

Rokitansky says (vol. iii. page 285) : " With regard to the question to 
be decided by the theory and microscopic examination, as to the nature of 
the added material upon which the increase of volume depends, I have 
formed the following opinion from repeated investigations : 

"1. The disease is genuine hypertrophy. 

"2. It consists, as such, not in an increase in the number of nerve- 
tubes in the brain, from new ones being formed, nor in an increase in the 
dimensions of those which already exist, either as thickening of their 
sheaths, or as augmentation of their contents, by either of which the nerve- 
tubes would become more bulky ; but, 

"3. It is an excessive accumulation of the intervening and connecting 
nucleated substance." 

It is now generally admitted that the views of Rokitansky are correct ; 
that hypertrophy of the brain is due to an augmentation in the amount of 
connective tissue, which lies between and unites the tubules. 

Causes. — Hypertrophy of the brain results from an error in the nutri- 
tive process which sometimes seems to be associated with the rachitic state, 
or a condition analogous to rachitis. It is not common, is indeed rare, in 
this country, and is more common in countries like England, where rachitis 
is more prevalent than with us. Rilliet and Barthez consider frequent 
congestions of the brain as a common cause. The hypertrophy is most 
frequently met in hospitals for children, and among the poor of the cities., 
whose systems are rendered cachectic by residence in damp and dark 
localities, and by unwholesome diet. In the deep valleys of Switzerland, 
and in parts of South America and Asia, hypertrophy of the brain is 
common, under the name cretinism. It is associated with rachitis and 
stunted growth. The abnormal development which occurs in cretinism 
begins in infancy or early childhood, and the unfortunate subjects of it 
are short-lived. Cretinism has been attributed to a residence in localities 
wet and deprived in great measure of solar light, and to general disregard 
of the laws of health on the part of those affected as well as their parents. 

The observations of different physicians also establish a connection be- 
tween some cases of hypertrophy and the saturation of the system by lead. 



384 HYPERTROPHY OF BRAIN. 

In what way lead-poisoning leads to hypertrophy is obscure, but the con- 
current testimony of different observers is so strong, that we cannot doubt 
that it does sometimes have that effect. But in a considerable proportion 
of cases, as in the one presently to be related, the cause is obscure. 

Symptoms. — The symptoms, as is the case with most organic diseases of 
the brain, vary considerably in different patients. Sometimes there is, at first, 
more or less depression or languor. If the child be old enough to speak, he 
may complain of pain in the abdomen or limbs, evidently neuralgic, or of 
headache. After a variable time vomiting succeeds, and finally convul- 
sions, affecting the muscles of the face, as well as extremities ; the convul- 
sions are usually clonic, but sometimes, as regards at least the extremities, 
of a tonic character. The pupils may be contracted or dilated • there is 
restlessness alternating with drowsiness, and finally coma supceeds. 

Hypertrophy may continue a considerable time before serious symp- 
toms arise ; but when once developed, these symptoms ordinarily continue 
with more or less severity till death. Death commonly results within a 
week after their commencement, but sometimes not till several weeks 
have elapsed. When death occurs at an early period in the disease, there 
is usually firm ossification and union of the cranial bones, and, therefore, 
but moderate enlargement of the cranium. 

If hypertrophy commence at a period not far removed from birth, the 
bones, of course, yield more readily to the pressure, and acute symptoms 
do not occur so soon. After a time, however, in all or nearly all cases, 
convulsions supervene. These indicate the gravity of the disease, and are 
prognostic of its fatal termination. 

In a patient observed by Burnet, violent convulsions, followed by loss 
of consciousness, marked the commencement of acute symptoms. Five 
days subsequently, the following symptoms were recorded : mobility of the 
eyes, without expression ; pupils contracted, and directed upward ; di- 
vergent strabismus of the left eye ; the senses in their normal state, with 
the exception of sight ; the limbs move by volition. For a month there 
was little change. Then occurred drowsiness, and increased prostration, 
and five weeks later the child succumbed with the symptoms of double 
pneumonia. 

Such is the clinical history of hypertrophy. In cases of firm ossifica- 
tion of the cranial bones, and, therefore, no marked enlargement of the 
skull, the symptoms are similar to those which occur if the dimensions of 
the head be increased, but compression and death result sooner. 

The following case, in which the sutures were firmly united, I attended 
in 1864. The head was large, but not so large as to attract attention 
from its disproportion : 

Case. — A boy, aged two years and two months, had, when about one 
year old, intermittent fever, and since then his countenance was uniformly 
pallid, and his flesh soft. Weaned at the usual time, he remained well till 



DIAGNOSIS. 385 

the 1st of January, 1864. In the beginning of this month he was ob- 
served to be feverish for some days, and his appetite poor. His health 
then gradually improved, and he was thought to be entirely well. 

On the 26th of February he was suddenly seized with convulsions, gen- 
eral at first, but most severe and continuing longest on the left side. The 
convulsions lasted a little more than three hours. He recovered fully his 
consciousness by the following day, but his appetite remained poor ; he 
was no longer amused by his playthings, and was very fretful. The sur- 
face was pallid ; bowels constipated ; pulse but little, perhaps not at all, 
accelerated. He continued in this state till the 6th of March, when he 
had another slight convulsive attack, and from this time he never fully re- 
covered his consciousness. He was fretful if disturbed, his face generally 
pallid, while the pulse and respiration were not perceptibly altered. 

On the following day, the 7th, the left pupil was somewhat larger than 
the right, but both were sensitive to light. The difference in size con- 
tinued till near the close of life. Although vision was imperfect, if not 
altogether lost, the sense of hearing was not impaired. 

When questioned, he uniformly answered, " No," with a drawling 
voice, evidently not understanding what he said. 

As the disease advanced, the respiration became at times sighing ; but 
the rhythm of the pulse was not materially altered. The temperature of 
the surface was changeable, sometimes cool, sometimes warm, and the 
congested spots or patches, so common in cerebral affections, were also 
observed at times on the face, ears, or forehead. Through most of his 
sickness he took drinks readily, and the urine was freely discharged, pro- 
bably from the iodide of potassium, which he took in one and a half grain 
doses every two hours. 

He became more and more drowsy, again had slight convulsive move- 
ments, and finally died, with much apparent suffering, on the 14th of 
March. The pulse became more accelerated during the last two or three 
days. On the day preceding his death, the pupils were contracted, and 
not affected by the light. 

Sectio Cadav. — Body somewhat emaciated, and eyes sunken ; occipito- 
frontal circumference of head nineteen and a half inches ; distance from 
one auditory meatus to the other over the vertex, thirteen and a half 
inches ; convolutions over the surface of the brain much flattened and 
compressed ; brain generally deficient in blood ; medullary substance firm, 
and of a pure white color ; meninges healthy ; no other abnormal appear- 
ances were observed ; weight of brain forty-two ounces. 

Diagnosis. — The diagnosis of hypertrophy is not always easy. The 
symptoms are, in the main, such as occur in other pathological states, 
especially congenital hydrocephalus. There is most danger of mistaking 
the overgrowth for this disease. Hypertrophy has, indeed, often been 
treated for hydrocephalus. There are, however, certain signs by which 
we may distinguish one from the other. In the ordinary form of con- 
genital hydrocephalus, even when the amount of liquid is small, the orbital 
plates of the frontal bones are pressed in such a way that the axis of the 
eyes is changed so as to have a downward direction. The white of the 
eye can be seen between the iris and the upper eyelid. This gives a char- 
acteristic and striking expression to the face. The exception to this is in 
25 



386 HYPERTROPHY OF BRAIN. 

those rare cases in which the liquid is external to the brain. In hyper- 
trophy this peculiar change in the axis of the eyes does not occur. More- 
over, in hypertrophy there is not that uniform expansion of the head 
which is observed in hydrocephalus, as has been stated above. There are, 
commonly, greater enlargement, more prominence of the anterior fon- 
tanels, and wider separation of the cranial bones, in hydrocephalus than 
in hypertrophy. But since in some cases of hydrocephalus the sutures 
are united, and the fontanelles closed, and there is no change in the 
direction of the eyes, the reason of the difficulty in making a positive 
differential diagnosis between these two diseases in certain instances is 
apparent. 

Hypertrophy with consolidation of the cranial bones, and, therefore, lit- 
tle enlargement of the head, may be mistaken for meningitis. The history 
of the case, and the means by which we diagnosticate the latter affec- 
tion, which will be described in their proper place, w T ill usually enable the 
physician to make a correct diagnosis. 

Prognosis. — In forming an opinion as to the probable termination of 
the disease, we must have regard to the age and general condition of the 
child, as well as to the degree of hypertrophy. If the disease commence 
at an early age, when the cranial bones are not firmly united, it is probable 
that there will be no compression of the brain, so as to endanger life, for 
a considerable period. We may then hope by proper measures to remove 
the constitutional state which gives rise to the hypertrophy, before the 
enlargement is such as to cause cerebral symptoms. If the bones have 
already united when the disease commences, even slight hypertrophy will 
produce symptoms, and a speedily fatal result is inevitable. Evidently,, 
also, a child in a marked degree rachitic or scrofulous is much less likely 
to recover than one whose general health and constitution are less im- 
paired. 

Treatment. — The treatment in hypertrophy should be directed mainly 
to the constitution. Measures calculated to improve the nutritive process 
are those most likely to check the abnormal growth of the brain. As the- 
disease is one of perverted nutrition, and usually coexists with a vitiated 
or impoverished state of the blood, tonic and alterative remedies are re- 
quired. The syrupus ferri iodidi is, therefore, useful, as it is both tonic 
and alterative. This may be given in doses of three or four drops to a 
child one year old, three times daily. Cod-liver oil, with or without the 
iron, is beneficial in some cases. Another remedy is iodide of potassium 
in combination with a tonic, as the compound tincture of bark. 

5 • Potas. iodid., 3 j ; 

Tinct. cinchon. comp., 
Syr. limon. , aa 1 ij . Misce. 
One teaspoonful, three times daily, to a child of three years. 

The hvgienic treatment is not less important than the medicinal. There- 



THROMBOSIS IN THE CRANIAL SINUSES. 3S7 

is little hope of a favorable issue in any case, unless the regimen be such 
as will conduce to a more robust and healthy state of system. The diet 
should be plain and nutritious, the apartments clean and airy, and all 
undue excitement should be avoided. 



CHAPTEE IV. 

THROMBOSIS IN THE CRANIAL SINUSES (PHLEBITIS). 

The formation of fibrinous coagula within a vein or sinus is designated 
thrombosis {thrombus, clot). Coagulation of fibrin in the cranial sinuses 
occasionally occurs, constituting a very serious pathological state. This 
may result from local disease in the sinuses or in their vicinity, or from 
disease external to the cranium. The immediate cause of thrombosis, 
whatever its location, is sufficient arrest of the circulation to allow the 
fibrin to coagulate. 

Tubercular and enlarged bronchial glands, compressing more or less the 
venae innominatae, or the descending vena cava, sometimes give rise to 
thrombosis in the cranial sinuses, the fibrin coagulating in consequence of 
retardation in the current of blood. I have known thrombosis, in the 
same situation, also to result from clonic convulsions, occurring in connec- 
tion with severe spasmodic cough in pertussis, since both the cough and 
convulsions retard the flow of blood in the veins and sinuses within the 
cranium. At the post-mortem examination of at least four such cases I 
found whitish clots in the lateral sinuses. 

Thrombosis, in the cranial sinuses, may also occur from inflammation, 
either in the walls of the sinuses or immediately exterior to them. This 
is the disease which writers have designated phlebitis of the cranial 
sinuses, and for a correct understanding of the morbid anatomy of which 
the profession are indebted to Yirchow. 

Anatomical Characters. — If a child die with the cranial sinuses 
and the veins of the brain and of the meninges in their normal state, the 
blood in these vessels is found at the autopsy dark but liquid, or there are 
small, dark, and soft clots in the larger sinuses. If there were congestion, 
but no coagulation, in these vessels in the last hours of life, the clots are 
more numerous, larger, and longer, sometimes extending from the sinuses 
into the larger veins which empty into them, but they are still dark and 
soft, readily falling to pieces when handled. If, again, there have been 
that degree of congestion and stasis which has resulted in ante-mortem 
coagulation, or in thrombosis, the clots are, in part at least, whitish, and 
of a fibrinous or gelatinous appearance ; they were formed while the red 
corpuscles were still earned along in the circulation. 



388 THROMBOSIS IN THE CRANIAL SINUSES. 

Most of the clots in thrombosis are free, while others are attached 
lightly to the internal surface of the sinus ; occasionally they are so large 
as to distend the vessel. They extend also in many cases into the cerebral 
veins which connect with the sinuses, producing prominence and firmness, 
so as to resemble (Rilliet and Barthez) an artificial injection. The clots 
do not present a uniform character. In parts of a sinus they consist of 
almost pure fibrin, of a yellowish-white color, while in other portions they 
present a gelatinous appearance from the large number of white cor- 
puscles, while other portions are more or less tinged from the presence of 
red corpuscles. The central part of the clot, after a time, if the case be 
sufficiently protracted, softens, and presents a puriform appearance. This 
substance, which is only disintegrated fibrin, was supposed to be pus, till 
the microscope revealed its true character. It is obvious that small clots 
forming within a sinus, and having no attachment to its walls, are liable 
to be carried by the current of blood into the general circulation, unless 
there be complete obstruction. Virchow has also shown how a thrombus 
may extend, by gradual prolongation, nearer and nearer the heart, so that 
one commencing in a sinus may, after a time, reach into the jugular vein. 
Different observers, as M. Tonnele, and also Rilliet and Barthez, have 
traced the fibrinous masses as far as the cava. The latter writers relate 
the case of a girl, four and a half years old, in whom the sinuses on the 
left side, especially those nearest the petrous portion of the temporal bone, 
were completely filled with clots of a yellowish- white color, intermixed 
with central dark spots. Similar coagula were also found in the left 
jugular vein as far as the brachio-cephalic trunk. Whether the walls of 
the sinus undergo any change depends on the nature of the disease which 
causes the thrombosis. If it be phlebitis, the coats are thickened from 
infiltration and injected, and the internal coat has lost its polish. If it 
be some obstructive disease in the course of the circulation, or a general 
cause, the coats of the vessel are unaltered, except that they may be 
stained by imbibition of the coloring matter of the blood. In an infant 
who died of this disease in the practice of Dr. West, ' ' the sinuses on the 
left side were healthy, but the blood was almost entirely coagulated. The 
posterior half of the longitudinal sinus, the torcular, the left lateral, and 
the left occipital sinuses, were blocked up with fibrinous coagula, pre- 
cisely such as one sees in inflamed veins, and the clot extended into the 
internal jugular vein. The coats of the longitudinal, and of the inner 
half of the lateral sinus, were much thickened, and their lining membrane 
had lost its polish, was uneven, and presented a dirty appearance." 

The mode in which congestion and coagulation occur within a sinus, in 
consequence of the pressure of a tumor upon this vessel, or upon a vein 
into which the blood from this sinus flows, is sufficiently obvious. The 
mode of the production of thrombosis, as a result of clonic convulsions, or 
of the spasmodic cough of pertussis, is also apparent. How it results 



causes. 389 

from inflammation of the walls of a sinus, that is, from phlebitis, was not 
understood till explained by Virchow. 

The fibrinous coagula which fill the sinus are not an exudative product, 
as was formerly supposed. Inflammation (in most cases otitis, with caries 
of the petrous portion of the temporal bone) approaches a sinus. The 
inflammatory products pressing against the walls of the sinus diminish 
its calibre at that point, and hence the retardation of the current of blood 
and the coagulation. Or the walls of the sinus may be thickened by in- 
flammatory infiltration, or even by the formation of little abscesses within 
the coats in consequence of the inflammation, so as to produce bulging 
inward, and the result, as regards the circulation, is the same. Whether, 
therefore, the inflammation occur without a sinus, or within its walls, 
thrombosis equally results, provided that the diameter of the vessel is 
sufficiently narrowed by the presence and pressure of inflammatory products. 

There is no exudation on the internal surface of a sinus or vein when in- 
flamed, as there is upon serous surfaces. " On the contrary" [Cellular Pa- 
thology, translation, p. 236), " when the wall is inflamed, the exuded matter 
(exsudatmasse) passes into the wall, which becomes thicker, cloudy, and 
subsequently begins to suppurate. Nay, even abscesses may form which 
cause the wall to bulge on both sides like a variolous pustule, without any 
coagulation of the blood ensuing in the cavity of the vessel. At other 
times, certainly, phlebitis, properly so called (and in like manner arteritis 
and endocarditis), is the cause of thrombosis, in consequence of the forma- 
tion of inequalities, elevations, depressions, and even ulcerations upon the 
inner wall which favor the production of the thrombus. Still, whenever 
phlebitis, in the usual sense of the word, takes place, the alteration in the 
coat of the vessel is almost always a secondary one, and, indeed, occurs at 
a comparatively late period." 

This view of the pathology of thrombosis comports with facts observed 
at autopsies, and which cannot be explained according to the old theory 
of phlebitis, namely, smoothness of the internal surface of the sinus ; 
natural color of this sinus, or simple staining from blood ; the non-attach- 
ment or slight attachment of the coagula, etc. 

Causes. — Some of these have been already stated at the commencement 
of this article. It is evident from what has been said that this disease may 
be produced by any cause which obstructs the return circulation from the 
head. I have already alluded to tumors which press upon the sinus, or 
on the vein below the sinus, as a cause. Among the causes may be men- 
tioned also abdominal tumors, narrowing of the chest from rachitis, or 
caries of the vertebrae, and, finally, compression of the jugular vein by a 
retropharyngeal abscess. 

Sufficient allusion has already been made to inflammation of the internal 
ear as a not infrequent cause. Thrombosis is, indeed, one of the dangerous 
results of chronic otitis. Another cause is a reduced or cachectic state of 



390 THROMBOSIS IN THE CRANIAL SINUSES. 

system, apart from any local or obstructive disease. It is a noteworthy 
fact that a large proportion of those affected with thrombosis, even when 
it is immediately due to obstructive disease, are cachectic. The explana- 
tion of this fact is not difficult. In reduced states of the system the 
action of the heart is feeble, and passive congestion of the vessels within 
the cranium is apt to occur. Passive congestion of the veins and sinuses 
in protracted diarrhceal maladies, which is described in our remarks upon 
another disease, is an example in point. In this state of feeble circula- 
tion very slight obstructive disease may be sufficient to cause thrombosis. 

Symptoms. — The symptoms of this disease are often obscure. All of 
them may and do occur in other maladies of the encephalon. In cases re- 
lated by M. Tonnele, cerebral symptoms were well marked, such as faint- 
ness, dilation of the pupils, strabismus, grinding the teeth, convulsive 
movements. There may be an almost total absence of such symptoms as 
would direct attention to the state of the head. This is due to the sudden 
occurrence of death after the clots have formed in the sinuses. If the clots 
are large, death soon results in consequence of congestion of the brain 
and meninges, which is proportionate to the amount of obstruction. Ex- 
travasations of blood and transudation of serum not infrequently accom- 
pany the congestion and hasten the result. 

Dr. West relates the case of a girl who had a mild attack of scarlet fever 
at the age of eight months, and did not fully recover her health. She con- 
tinued restless and feverish, and had two violent convulsions two weeks 
after the scarlatina. In the following months she had anasarca, and when 
she was nearly a year old another attack of convulsions occurred. Fluctua- 
tion was now observed in the abdomen, and in a few days a sero-purulent 
fluid began to escape from the umbilicus. When this discharge had con- 
tinued eleven days, symptoms of a liquid in the right pleural cavity were 
suddenly developed. She grew weak and emaciated, and finally was seized 
with extreme faintness, with which she died in forty- eight hours, at the 
age of thirteen and a half months. 

At the post-mortem examination a large amount of pus was found in the 
abdominal and right pleural cavities. On the right side of the cranium, 
the sinuses were filled with coagula, and their coats seemed healthy. The 
left lateral and occipital sinuses, the torcular and part of the longitudinal 
sinus, also contained coagula, which extended into the jugular vein. The 
walls of the longitudinal sinus and the internal part of the lateral sinus 
were thickened, and their inner surface had lost its polish and was uneven. 
There was congestion of the brain, with points of extravasated blood. If, 
as is probable, the convulsions were due to some other cause, the only 
symptom which was clearly referable to the thrombosis was the sudden 
faintness. In the four cases of thrombosis occurring in pertussis, already 
alluded to, in which I was enabled to ascertain by post-mortem exami- 
nation the presence and extent of the clots, the symptoms, which were 



CONGESTION OF THE BRAIN. 391 

apparently due to the thrombosis, were those of cerebral congestion. 
Among these symptoms, stupor, and finally coma were prominent. The 
convulsions which occurred in both cases were apparently a cause, and not 
a result, of the thrombosis. 

Diagnosis. — It is evident, from what has been said, that thrombosis of 
the cranial sinuses can rarely be diagnosticated with certainty. The pre- 
existence of otitis will sometimes lead us to suspect its presence, especially 
if the otitis have been accompanied by deep-seated pains. Symptoms of 
•cerebral congestion, serous effusion, or apoplexy, occurring in connection 
with otitis, protracted convulsions, or glandular or other tumors situated 
■so as to compress the vessels which return blood from the brain, indicate 
thrombosis. 

Prognosis. — The prognosis, in any case, is obviously unfavorable. 
The cause is, ordinarily, permanent, or not readily removed, so that the 
clots gradually increase. If the cause be a local obstructive disease, death is 
almost certain, since, in nearly every instance, the obstruction is of such 
a nature that it cannot be removed by medical or surgical treatment. It is 
possible that recovery may take place if the clots are few and small, and 
the cause of the thrombosis is mainly feebleness of circulation in conse- 
quence of a state of debility. We know that clots may liquefy, and their 
elements re-enter the circulation ; but such a result of thrombosis in a cra- 
nial sinus, if it ever occur, is rare. The thrombus, by its presence, serves 
as a point of attachment around which more fibrin coagulates, so that the 
obstruction gradually increases till death occurs. 

Treatment. — Thrombosis should be treated by cool applications to the 
head, in order to diminish the congestion, by stimulants and sustaining 
measures in case the systolic movement of the heart is feeble. Tonics, 
vegetable or ferruginous, are indicated if there be a cachectic state. 



CHAPTEE V. 

CONGESTION OF THE BRAIN. 

Congestion of the brain is not peculiar to infancy and childhood, but 
is much more common in these periods of life than subsequently. This is 
due, in a great measure, to the fact that in the young the circulation is 
more readily disturbed by moral as well as physical causes than in the 
adult. 

Congestion of the brain is occasionally primary ; more frequently it oc- 
curs as a concomitant or sequel of some other affection. Diseases, whether 



392 CONGESTION OF THE BRAIN. 

constitutional or local, which in the adult have no appreciable effect on 
the vascularity of the brain, often cause in the child a decided increase of 
blood in this organ. 

Causes. — Cerebral congestion is of two kinds, active and passive. The 
former results from a cause which directly affects the brain, and increases 
the flow of blood toward it, or from a cause operating primarily on the 
heart, and increasing the frequency and force of its systolic movement ; 
the latter is due to some obstruction in the course of the circulation, or to 
feeble propelling power on the part of the heart. 

Among the causes which most frequently produce active congestion of 
the brain in the child, may be mentioned blows or falls on the head, ex- 
cessive fatigue or excitement, heat, perhaps sometimes dentition, and also 
various inflammatory and febrile affections, especially in their first stages. 

Cerebral symptoms occurring in the course of an essential fever are no- 
doubt often due, in a great measure, to the irritating effect on the brain of 
the specific principle, whatever it may be, circulating in the blood. Oc- 
curring in inflammatory diseases which are located elsewhere than within 
the cranium, they are often attributed to functional disturbance of the 
brain. The brain, it is said, sympathizes with the affected part through 
the system of nerves which unite them. But observations show that symp- 
toms referable to the brain, arising in the commencement of the essential 
fevers and of the phlegmasia, are in many instances preceded by, and are 
therefore, doubtless, in greater or less degree dependent on, hyperemia of 
this organ. 

Difficult as it is to ascertain the state of the brain in many diseases in 
which it is involved, we may determine whether or not there be congestion 
in the young child by observing the anterior fontanelle. If it be elevated 
and tense in an acute disease, hyperemia is indicated. Now, it is often 
unusually prominent in fevers and inflammations, especially in their first 
stages, when cerebral symptoms are present. Its elevation, under such 
circumstances, is obviously coincident with cerebral congestion. 

The acute inflammations which are most likely to be attended by cere- 
bral congestion are those of the mucous surfaces and pneumonia. Severe 
coryza, tracheo-bronchitis, entero -colitis, and colitis, commencing suddenly 
with great febrile excitement, are frequently accompanied in their initial 
stage by active congestion of the cerebral vessels. Cases like the follow- 
ing, which I find in my note -book, are not infrequent. An infant four 
months old had been sick about two days with coryza and bronchitis, when 
I was called to see it ; the pulse numbered 156 ; respiration 64 ; it nursed, 
and was somewhat restless ; cough frequent and dry ; bowels moderately 
relaxed. The mucous membrane of the fauces was injected, and coarse 
mucous rales were present in the chest. The anterior fontanelle rose above 
the level of the cranium, and pulsated forcibly. Soon after convulsions- 
occurred, which were relieved by appropriate measures, and on the follow- 



causes. 393 

ing day the fontanelle Lad subsided. The patient gradually recovered! 
without any untoward symptom. 

Cerebral congestion and convulsions often mark the initial stage of 
active intestinal phlegmasia. This is especially true of dysentery. The 
little patient, perhaps from the very inception of the colitis, is drowsy ; its- 
surface hot ; pulse full and rapid. There is sudden and momentary start- 
ing or twitching of the limbs. The anterior fontanelle, if still open, is 
elevated, and it is not till the lapse of several hours that the cause of these 
symptoms is apparent from the occurrence of bloody stools. 

The causes of passive congestion of the brain are very different from 
those of the active form. A common cause is obstruction in a sinus or 
vein by a fibrinous concretion, or by a tumor or abscess external to it. 

I have occasionally met cases in which this form of cerebral congestion 
appeared to be plainly referable to obstruction to the return of blood from 
the brain by the pressure of bronchial glands, enlarged by hyperplasia in 
tubercular disease, these bodies diminishing by external pressure the 
calibre of the venae innominatae or the descending vena cava. Rilliet and 
Barthez have called attention to such cases in the clinical history of tuber- 
culosis. The following case may be cited as an example ; it occurred in 
the infants' service of Charity Hospital, in this city, in April, 1866. 

An infant, about one year old, affected with tuberculosis, both bronchial 
and pulmonary, was observed, during the ten days preceding its death, to 
bore the pillow with its head almost constantly, so as to wear the hair from 
the occiput. This movement of the head was the only prominent cerebral 
symptom. Nothing abnormal was noticed in the appearance of the eyes, 
nor was the stomach irritable. A spasmodic cough and progressive emacia- 
tion attracted attention, but these were referable to the tubercular disease.. 
At the autopsy we found the cerebral sinuses, veins, and capillaries greatly 
congested. On tracing the veins which return blood from the brain, an 
inflamed and enlarged bronchial gland was discovered in the angle formed 
by the convergence of the right and left venae innominatae. This gland,, 
which contained but a single point of cheesy degeneration, had attained 
such a volume by proliferation of its cells that it pressed upon both ves- 
sels, so that it had obviously retarded the circulation in each, and given 
rise to cerebral congestion. 

Passive congestion often occurs in the infant at birth, either from tedi- 
ousness of the labor or delay in the expulsion of the body after the birth 
of the head. If it be simple congestion, and not congestion with haemor- 
rhage, it soon passes off. Passive congestion of the brain also occurs in 
severe paroxysms of hooping-cough, in which return of blood from this 
organ is temporarily retarded. All are familiar with the congestion which 
occurs in parts external to the cranium, from the severity of the cough ; 
producing epistaxis, extravasations under the conjunctiva, etc. The extra- 
cranial obviously indicates the presence and degree of cerebral congestion. 



394 CONGESTION OF THE BRAIN. 

Those who practise in malarious regions sometimes meet cases of dan- 
gerous passive congestion of the brain, the result of malaria, occurring 
■especially in the cold state of intermittent fever. In these cases the sur- 
face is pallid, its temperature reduced, and the pulse feeble. The blood, 
leaving the peripheral vessels, collects in undue quantity in the internal 
organs, producing congestion of the brain, as well as of the thoracic and 
abdominal viscera. In the child with malarial disease, in whom there is 
less vigor of constitution than in the adult, death not infrequently occurs 
in this passive congestion. Two such cases have occurred in my practice, 
although in this latitude the malarial maladies are mild in comparison 
with the type which they present in many parts of the United States. 

Symptoms. — The symptoms of active congestion of the brain are stu- 
por, great heat of head, throbbing of carotids, restlessness when aroused, 
twitching of the limbs, and perhaps convulsions. There is also some- 
times intolerance of light, and the anterior fontanelle, if open, pulsates 
strongly. In passive congestion many of the symptoms are the same as 
in the active form. Stupor, twitching of the limbs, and fretfulness or ir- 
ritability when the patient is disturbed, are common, ordinarily without 
increase of temperature ; the surface may, indeed, be cool, and the face 
is not flushed nor the eyes injected. The strong pulsation and elevation 
of the antericr fontanelle, so conspicuous in active congestion, are — the 
former always, the latter often — lacking. In both forms there is ten- 
dency to constipation. 

In many cases the symptoms of congestion of the brain are associated 
with others which proceed directly from the cause of the congestion, but 
it is not difficult, unless m exceptional instances, to determine which are 
due to the congestion, and which to the antecedent and coexisting patho- 
logical state. 

Anatomical Characters. — In active congestion there is an excess of 
arterial blood in the brain and its membranes. The arteries, to their 
minutest branches, are seen to be full, presenting the bright hue of oxy- 
genated blood. In passive congestion the sinuses and veins are distended. 
The pia mater, choroid plexus, and the vessels of the brain, have a darker 
appearance than in active congestion. In both forms of congestion, if 
they continue for a little time, other anatomical changes occur. If there 
be great distension of the capillaries, these vessels are apt to give way, and 
we find here and there little patches of extravasated blood. In other cases 
the over-distension is relieved by the transudation of the serous portion of 
the blood through the coats of the vessels. The cephalo-rachidian fluid is 
then found in excess external to the brain and in the ventricles. 

Prognosis. — The duration and the result of congestion of the brain de- 
pend, in great measure, on the nature of the cause. If the cause be trivial, 
.as mental excitement, fatigue, exposure to heat, there is usually prompt 
.relief if the condition of the patient be understood and properly treated. 



TREATMENT. 395 

If the cause be general or constitutional, as one of the essential fevers or 
hooping-cough, or if it be local, but its seat external to the cranium, the 
prognosis, so far as the congestion is concerned, is not unfavorable, if there 
be a timely and judicious use of remedies. The most unfavorable cases are 
those in which the cause is seated in the encephalon, and those in which 
there is some obstructive disease in the course of the circulation. Con- 
gestion occurring from a structural change within the cranium is, from 
the nature of the cause, without remedy, and ordinarily fatal. Obstruc- 
tive diseases of the circulatory system, wherever located, being for the 
most part permanent, give rise, as a rule, to incurable congestion. 

Congestion of the brain, if it be not relieved in a few hours, becomes 
less and less amenable to treatment. It soon passes beyond the resources 
of our art, and ends in coma ; it is seldom protracted beyond a few days. 
Extravasations of blood, common in active congestion, and serous effu- 
sion, common in the passive form, diminish the chances of a favorable 
result. 

Treatment. — The indication for treatment in active congestion is 
plain. Measures should be employed which produce derivation from the 
brain. Unless there be an asthenic primary affection, in the course of 
which the congestion is developed, active purgation is required. A saline 
purgative is ordinarily preferable. If the stomach be irritable, there is no 
better purgative than calomel. In all cases of active congestion, what- 
ever the cause, the bowels should Tie kept open. It is often better not to 
wait for the tardy action of a cathartic, but to give at once an enema of 
soap and water or salt and water. External derivative agents are also in- 
dicated. A warm mustard foot-bath, sinapisms to the back of the neck or 
chest, and to the feet, and cold applications to the head, are measures 
which should never be neglected. 

This treatment, if employed early, will relieve the congestion in a large 
proportion of cases ; but if there be no improvement, if the child be robust, 
and if the primary affection be such as does not contraindicate loss of 
blood, leeches should be applied to the temples or some part of the head. 
If after the lapse of some hours cerebral symptoms continue, apoplexy or 
serous effusion has probably occurred. Congestion is then no longer the 
prominent lesion, and it is proper to designate the disease by another 
name. 

The treatment appropriate to passive congestion is somewhat different ; 
cold applications to the head, and those of a derivative nature to the ex- 
tremities, are useful. As this form of the disease is not primary, but is 
dependent on some antecedent pathological state, it is evident that it can 
only be treated successfully by removing or obviating so far as possible 
the cause. But the nature of the various obstructions to the intracranial 
circulation is such that our ability to accomplish this end is very limited. 

If the cause be constitutional, or if it be some disease in the neck or 



396 INTRACRANIAL HEMORRHAGE. 

chest, it may sometimes be partially or even wholly removed, but if seated 
within the cranium it is beyond our control. In general, it may be said 
that depletion is not required or tolerated in passive congestion, and stimu- 
lants are often needed. 



CHAPTER VI. 

INTRACRANIAL HEMORRHAGE (MENINGEAL HEMORRHAGE. CERE- 
BRAL HEMORRHAGE). 

Haemorrhage within the cranium is not very infrequent in infancy 
and childhood ; and there is no part of the encephalon, whether the me- 
ninges or brain, in which it does not sometimes occur. If the blood be 
extravasated upon the surface of the brain or between the meninges, the 
disease is designated by writers meningeal apoplexy ; if in the substance 
of the brain, cerebral apoplexy. Extravasation may also occur in one of 
the lateral ventricles. This may, for convenience, be described as a form 
of meningeal apoplexy. 

Causes. — Apoplexy is usually (there is an exception) preceded by con- 
gestion. If the congestion increase to a certain degree, the distended 
capillaries give way and extravasation of blood results. Therefore the 
causes of congestion which have been enumerated in the preceding article 
are, in great measure, those of apoplexy. Eecent microscopic examina- 
tions have demonstrated that the corpuscular elements of the blood may 
escape from capillaries without rupture. While, therefore, it is probable 
that intracranial haemorrhage in early life commonly occurs from a rupture, 
its occasional occurrence through the walls of the capillaries must be ad- 
mitted. 

Intracranial haemorrhage is not infrequent in the new-born. It results 
in them from tediousness of the birth and severity of the labor-pains. 
At first there is extreme congestion of the meningeal and cerebral vessels 
corresponding with that of the scalp and face. This congestion, continu- 
ing, soon ends in extravasation of blood. In some of these cases forceps 
have been used to effect the delivery, but it is doutful whether the use of 
instruments materially increases the congestion or the amount of extrava- 
sation. Certainly, in a large proportion of intracranial as well as supra- 
cranial haemorrhages of the new-born, instruments have not been used. 
An additional cause of the haemorrhage is, in some instances, the use of 
ergot, which, by producing strong and continuous pains, interrupts the 
placental circulation and increases the congestion of the foetal veins and 
the capillaries. 

In infants a few days old intracranial haemorrhage may result from 



ANATOMICAL CHARACTERS. 397 

that rapid and fatal disease, tetanus infantum. The haemorrhage is 
preceded by intense passive congestion, which the tetanic rigidity and 
spasms produce by obstructing respiration and circulation. Few cases of 
tetanus infantum occur without more or less extravasation of blood, either 
meningeal or cerebral. Another cause of this disease is obstruction in 
the vessels which return the blood from the brain. The various structural 
changes which produce this obstruction, in different cases, have been 
sufficiently described in our remarks on cerebral congestion and throm- 
bosis. 

The congestion which precedes haemorrhage, when occurring under the 
conditions described above, is passive. 

Among the causes which produce haemorrhage through the intermediate 
state of active congestion may be mentioned great mental excitement, of 
which M. Legendre relates a case, and lengthened exposure to the sun's rays, 
an example of which Rilliet and Barthez have seen. It is also said that 
compression of the aorta by an enlarged liver or an abdominal tumor has 
sometimes produced meningeal or cerebral haemorrhage, by causing an 
increased afflux of blood to the head. A very important cause to which 
I have not alluded, is that general state of the circulatory system which 
is designated by the term purpura haemorrhagica. This sometimes results 
from the anti-hygienic conditions in which the child is placed. In other 
instances it results from some antecedent disease, protracted and debili- 
tating, which has produced a profound alteration in the state of the blood 
and the vessels. The capillaries become less firm and elastic, and easily 
give way, so that in such patients ecchymotic points are ordinarily found 
in different parts of the system. The diseases which occasionally end in 
this haemorrhagic diathesis are numerous. I have known it to occur after 
measles, scarlet fever, and smallpox. It is also an occasional sequel of 
chronic diarrhoea, of intermittent and typhoid fevers, and of rachitis. 

Anatomical Characters. — Haemorrhage in or upon the brain, in 
infancy and childhood, differs in important particulars from that occur- 
ring in adult life. In the adult, and more so as life advances, the arteries 
become less distensible and more brittle, so that when haemorrhage occurs 
it is usually from one of these vessels. In early life, on the other hand, 
the blood does not ordinarily escape from an artery, but, as has been 
stated, from the capillaries. The extravasation is not, therefore, so rapid 
and violent, and is not attended with such laceration and injury of sur- 
rounding parts, in infancy and childhood, as at a subsequent age. In the 
adult the haemorrhage commonly occurs in the substance of the brain. 
The flow of blood from the ruptured artery separates the brain-substance, 
producing a cavity in which a clot forms. This constitutes the usual form 
of apoplexy in the adult. In the first years of life, on the contrary, the 
extravasation is commonly from the meninges, and the symptoms to which 
the effused fluid gives rise are for the most part due to its mechanical 



398 INTRACRANIAL HEMORRHAGE. 

effect. Cases of haemorrhage in the substance of the brain constitute a 
small minority, unless during the days immediately succeeding birth. In 
early life, therefore, on account of its greater frequency, meningeal haemor- 
rhage is a disease of more importance than cerebral, and its anatomical 
character should be carefully studied. 

In meningeal hemorrhage the extravasation may be between the cranium 
and dura mater, upon the visceral layer of the arachnoid, in the meshes 
of the pia mater, or in a lateral ventricle, from rupture of the capillaries 
in the choroid plexus. Much the most common seat is external to the 
pia mater in the so-called cavity of the arachnoid ; the blood escaping in 
this situation spreads uniformly in all directions. It soon separates in two 
portions, the solid and liquid. The solid portion, or the clot, is free or but 
slightly attached to the adjacent membrane. The meninges in the vicinity 
of the extravasated blood preserve their normal appearance, or are but 
slightly injected ; the clot gradually becomes extended on all sides, so as 
to form a lamina at the seat of the extravasation, thinner at its circum- 
ference than centre, and at first of a dark-red color. The color gradually 
fades, and the lamina, becoming smooth and polished, and at the same tim& 
more and more attenuated, finally resembles the arachnoid in appearance. 
Its diameter varies in different cases from a few lines to two or three or 
more inches. M. Tonnele relates two observations m which the adven- 
titious membrane extended over the superior surface of both hemispheres, 
and in one of them, also, over the falx cerebri. 

The extravasation may occur at any part of the surface of the brain, but 
its usual seat is the vertex. The next most frequent locality is the base of 
the brain. The subsequent history of the delicate membrane into which 
the clot is gradually transformed is interesting. It often extends so as to 
cover more space than was occupied by the extravasated blood, and its 
edges are then scarcely distinguishable, in consequence of their extreme 
tenuity, and their close resemblance to the arachnoid. The attachments of 
this membrane, so far as it forms any, are usually to the parietal surface 
of the arachnoid. Sometimes a portion of the membrane is attached, while 
the rest lies free, bathed on either side by the liquid portion of the blood 
which still remains from the extravasation. According to M. Legendre, 
in the most favorable cases, the serum is absorbed, and the membrane 
which has resulted from the clot, and which I have described, becomes in- 
timately adherent to the internal surface of the dura mater. It forms an 
integral part of this membrane, and there only remain a little thickening 
and increased opacity, indicating the seat of the extravasation. The health 
is fully re-established. 

But the result in other cases is as follows : The serum is not absorbed, 
and the newly formed membrane, uniting at points with the inner surface 
of the dura mater, or its arachnoidal covering, incloses the fluid so as to* 
produce a circumscribed hydrocephalus. 



CEREBRAL HEMORRHAGE. 399 

Sometimes there is only one cyst ; in other instances the membrane,, 
especially if large, unites in such a way as to give rise to more cysts than 
one. The size of the cyst varies, according to the quantity of fluid, which. 
may be only a few drachms or several ounces. Rilliet and Barthez report 
a case in which there was a pint of fluid lying over each hemisphere, there 
being two cysts. If the cranial bones are not united, so that they yield to 
; the pressure, the size of the cranium is increased, and if the extravasation 
be confined to one side, an inequality results, and the symmetry of the head 
is destroyed. The fluid which causes the enlargement of the head in such 
cases is in part the serum of the extravasated blood, and in part a subse- 
quent secretion. 

Various writers relate cases of ventricular haemorrhage. Valleix met it 
in an infant that died at the age of two days. In the Edin. Jonrn. of 
Med. and Surg., October, 1831, an interesting case is related. A boy 
nine years old died of haemorrhage in both ventricles, and also at the base 
of the brain and in the spinal canal. In the Nursery and Child's Hospital 
of this city, the post-mortem examination was made of an infant who 
died at the age of one month. In the posterior cornu of the left lateral 
ventricle were two clots, elongated and black, one larger than the other. 
In the corresponding cornu, on the opposite side, was a smaller clot. A 
similar post-mortem appearance was observed at the autopsy of a young 
infant in the infant service of Charity Hospital. A dark crescentic clot lay 
in each posterior cornu. The clot, if remaining a long time, undergoes 
degeneration. In the case of an adult, in which a year had elapsed after 
the extravasation, I found it to contain crystals of cholesterin and car- 
bonate of lime. 

Cerebral Haemorrhage, or haemorrhage in the substance of the brain, 
may occur at any time in infancy and childhood. The blood is some- 
times extravasated in points, here and there, over the entire organ, or a 
part of the organ ; in other cases it is extravasated in one or perhaps two 
cavities, as in the ordinary form of apoplexy in the adult. In the first 
form of cerebral haemorrhage, or that in which the blood escapes from nu- 
merous points through the brain, there is evidently little laceration or 
injury of the organ. The brain-substance surrounding the haemorrhagic 
points sometimes preserves the usual appearance. It is white and firm. 
In other cases it presents a reddish or yellowish appearance, and is soft- 
ened to the depth of a line or two. If the haemorrhage occur in a cavity, 
as in apoplexy of adults, the nerve-fibres are evidently torn and sepa- 
rated, and there is more or less compression of the surrounding brain- 
substance. Unless the disease be of long standing, the cavity contains a 
dark and soft clot bathed with serum, which has a reddish or a yellowish- 
red appearance. The brain in the immediate vicinity of the cavity is 
sometimes softened. Rilliet and Barthez state that they have seen eight 
cases of cerebral haemorrhage of the capillary form ; ten cases in which the 



400 INTRACRANIAL HAEMORRHAGE. 

haemorrhage was in cavities ; and in two of the eighteen both forms were 
present. In five of those in which the form was capillary the disease was 
limited to portions of the brain, while in the remaining three the haem- 
orrhagic points were found in nearly every part of the brain. 

Apoplectic cavities are seldom seen in the cerebellum, and, whether the 
haemorrhage be capillary or in a cavity, there is, in most cases, as pre- 
viously stated, more or less congestion of the vessels of the brain. 

The proportion of cases of cerebral to other forms of haemorrhage is 
believed by some to be greater in the new-born than at any other period 
of life. Yalleix relates four cases of intracranial haemorrhage occurring at 
this age, two of which were cerebral, one ventricular, and in the other the 
extravasation was in the cavity of the arachnoid. Mignot has published 
eight cases occurring in the new-born, in two of which the haemorrhage 
was in cavities in the cerebrum ; in three, in the lateral ventricles ; and in 
"three, external to the brain. If the same proportion be observed in other 
statistics, one in three of the cases of intracranial haemorrhage occurring 
in the new-born is cerebral. 

Symptoms.- — The symptoms in intracranial haemorrhage are not uniform ; 
they vary according to the seat as well as the quantity of the effused 
blood. In some cases the extravasation occurs without such symptoms as 
would direct attention to the brain. When the haemorrhage occurs at the 
time of birth, in consequence of the strong and long-continued labor-pains, 
the infant is often born apparently dead. This is due partly to the haemor- 
rhage, partly to the great congestion of the brain which precedes and 
accompanies the haemorrhage. Resuscitation is gradual and difficult. The 
infant's features are livid, and perhaps swollen ; its respiration is gasping, 
and both pulse and respiration are slow. Its cry is feeble, with but slight 
movement of the facial muscles, and the lungs are but partially inflated ; 
the eyelids are closed, and the limbs almost motionless. By artificial 
respiration and by friction, the pulse and breathing may be rendered more 
frequent, but the latter remains irregular and gasping. Finally, the limbs 
grow cold, the surface, from a state of lividity, becomes pallid, and death 
occurs in profound coma. M. Cruveilhier made many observations at the 
" Maternity" in reference to the death of new-born infants, and he be- 
lieves that one-third of those who die in birth, at the full period, die of 
apoplexy. I have made post-mortem examinations in a few cases, when 
death had occurred from this cause, and in all the haemorrhage was menin- 
geal. One of these was born on the 30th of December, 1864. The birth 
was delayed by unusual projection of the promontory of the sacrum, so 
that finally the application of forceps was necessary. The infant was ap- 
parently still-born, but by persistent efforts on the part of the physician 
who assisted it was resuscitated so as to live several hours, though with 
constant embarrassment of respiration and with lividity. At the autopsy 
a large extravasation of blood was found in the cavity of the arachnoid, 



SYMPTOMS. 401 

over a considerable part of the convexity of the brain, and the substance 
of the brain was deeply congested. 

Apoplexy in the new-born does not always terminate fatally, or, when 
fatal, in the sudden manner which I have described. Valleix relates the 
case of an infant who died of pneumonia at the age of three and a half 
months. Its birth had been protracted and difficult, but was completed 
without the use of instruments. It had had during its entire life paralysis 
of the right side. At the autopsy a clot was found near the base of the 
right thalamus opticus, evidently existing from birth. Around the clot 
the brain was softened to the depth of some lines, and was of a bluish- 
red color. A very similar case is related by M. Yernois. An infant lived 
forty-nine days with paralysis of the left side, and died of pneumonia. At 
the autopsy a haemorrhagic excavation in the process of cicatrization was 
found behind the right corpus striatum and the thalamus opticus. 

Intracranial haemorrhage occurring from accidents of birth is generally 
attended by marked symptoms, such as have been described. But when 
it occurs subsequently to birth, whether in infancy or childhood, the symp- 
toms vary greatly in different cases, and are generally obscure. I will 
briefly state the symptoms which have been observed in both the cerebral 
and meningeal forms of this disease. First, the cerebral. Sedillot relates 
the case of a child seven and a half years old, whose bare head had been 
exposed several hours to the sun's rays. Suddenly, after a paroxysm of 
anger, it was seized with great pain, corresponding with the posterior and 
inferior fossae of the cranium. It uttered piercing cries, and died in a 
quarter of an hour. A clot was found in the right lobe of the cerebellum. 
Richard Quinn (Rilliet and Barthez) gives the history of a boy nine years 
old, who in playing with a hoop suddenly stopped, carried his hands to 
his head, and fell backward unconscious. Three or four hours after- 
ward when examined, he was found pale, surface cool, respiration slow 
and at times stertorous, pulse 50 to 60 per minute ; the left arm was 
flexed, the left leg paralyzed ; the right leg and arm convulsed ; right 
pupil strongly dilated, the left contracted. He died seven hours after the 
commencement of the attack, and a large clot was found in the centrum 
ovale on the right side. 

Rilliet and Barthez relate the following case from Campbell. A boy 
with good previous health was suddenly seized about 1 a.m. with repeated 
vomiting, and in an hour and a half with violent convulsions ; he rolled his 
eyes and uttered inarticulate cries ; pulse frequent and hard ; pupils con- 
tracted ; trunk and lower extremities cool. In the afternoon he presented 
symptoms of compression of the brain, such as dilatation of the pupils, 
frequent and feeble pulse. Death occurred in the evening, and a haemor- 
rhagic cavity was found occupying the right middle lobe of the cerebrum. 
Guibert relates a case of extravasation in the superior part of the right 
hemispheres of the brain in a boy fourteen years old. The principal symp- 
26 



402 I N 'I 1 R A C R A N I A L HEMORRHAGE. 

tonis were feebleness: of the limbs, inability to walk, cephalalgia, involun- 
tary evacuations, fever, grinding of the teeth, rigors severe and prolonged,, 
lividity, loss of intellectual faculties, dilatation of the pupils, insensibility 
to light, stertorous respiration. Death occurred in about an hour. 

Rilliet and Barthez narrate the history of a girl two years old, who, 
after an attack of measles, was taken with convulsions accompanied with 
fever and prostration. The convulsive movements affected especially the 
eyes and upper extremities ; the right leg was immovable ; the left pupil 
dilated. These symptoms resulted from haemorrhage in the corpus striatum 
and opticus thalamus. The same authors relate also the case of a girl, 
seven years old, who died with a large apoplectic cavity in the left thala- 
mus opticus. The symptoms were headache, convulsive movements, loss 
of consciousness, delirium, vomiting and constipation, and convergent 
strabismus. These symptoms nearly disappeared, but in a few days the 
headache returned, with strabismus and a slight drawing of the face 
toward the left ; on the twenty-seventh day convulsive movements of 
the right eye were observed, with paralysis of the arm. Finally contrac- 
tion of the arms occurred, w 7 ith acceleration of pulse, irregular breathing, 
dilated pupils, paralysis, and retraction of the head, followed by death on 
the forty-eighth day. 

These cases, and those from Valleix and Vernois, which have been re- 
lated in our remarks on haemorrhage of the new-born, are sufficient to show 
the character of the symptoms in that form of cerebral haemorrhage in 
which the extravasated blood forms a cavity in the interior of the brain. 

If the amount of extravasation be large, and the substance of the brain 
be much lacerated and compressed, death may occur almost immediately, 
and, therefore, without symptoms, or before it is possible to determine 
whether or not symptoms are present. If the disease be not so speedily 
fatal, the symptoms, as appears from the above cases, are headache, con- 
fusion of thought, or even insensibilty, cries, sometimes piercing, cold ex- 
tremities, pallor, slow and perhaps stertorous respiration, convulsive move- 
ments followed by paralysis, or convulsions affecting one or more limbs, 
with paralysis of others, pupils contracted or dilated, sometimes one con- 
tracted and the other dilated, strabismus, rolling of eyes, vomiting. 

These symptoms have all been observed in different cases, but they are 
not all present in any one case. Those which are generally present, and 
on which we mainly rely for diagnosis, are headache, convulsive move- 
ments, paralysis, confusion of thought, irregularity in the pupils, and 
strabismus. 

In the capillary form of cerebral haemorrhage there is usually some 
complication, so that it is not easy to determine how far symptoms are 
due to the haemorrhage, and how far to the coexisting pathological state. 

There are, indeed, but few published observations of capillary haemor- 
rhage in the substance of the brain uncomplicated with meningeal haemor- 



M E X I X G E A L H M M ORE H AGE. 403 

rhage, haemorrhage into a ventricle, or some other and distinct disease, but 
so far as I have been able to ascertain the symptoms referable to this form 
of extravasation, they are as follows : The child is drowsy ; fretful when 
disturbed ; it perhaps moans. There are sometimes slight convulsive move- 
ments and partial paralysis. If there be considerable extravasation, the 
respiration is irregular and sighing. Death occurs in coma, occasionally 
preceded by convulsions. Taupin relates the case of a child nine years 
old, who died with this form of haemorrhage, accompanied by softening 
of the brain. The disease began at night, with delirium, agitation, and 
piercing cries. In the morning the patient lay in bed, drowsy, not com- 
plaining of pain, and not replying to questions ; pupils dilated, and in- 
sensible to light ; left eye half open during sleep, and its axis changed ; 
eyebrows contracted ; face pale ; mouth open ; had no convulsions, but 
transient stiffening of the limbs, during which the thumbs were firmly 
compressed by the fingers ; senses unimpaired, but the face drawn to the 
right ; deglutition difficult ; pulse small, irregular, and feeble ; respiration 
32, sighing. In the evening he had rigidity of the limbs and back, and, 
finally, was taken with general convulsions, in which he died at eleven 
o'clock. The hemorrhagic points in this case were numerous. A boy 
five years old, whose case is described by Rilliet and Barthez, died of this 
disease, pneumonia, and white softening of the intestine. During the last 
five days there were cerebral symptoms, the chief of which were drowsi- 
ness, fretfulness when disturbed, and moaning without apparent cause. 
Another child, whose case is described by Rilliet and Barthez, died at the 
age of four years, with cerebral capillary haemorrhage, accompanied by 
yellow softening. Six months before death he had general convulsions, 
followed by spasmodic movements of the left side. These subsided, but 
the left side remained feeble. 

In Meningeal Hemorrhage there are often convulsions, general or 
partial, in some patients tonic, in others clonic. When partial, the con- 
vulsive movements may only occur in the muscles of the face and eyes. 
With the spasmodic muscular action is a degree of drowsiness and irrita- 
bility. Paralysis, so common in the apoplexy of the adult, and not in- 
frequent, as we have seen, in the cerebral form of early life, is sometimes, 
but not ordinarily, present in meningeal haemorrhage. Instead of paraly- 
sis, there are vomiting, some febrile action, thirst, and loss of appetite. 
The symptoms are different, however, according to the exact seat of the 
hemorrhagic extravasation, and the duration of the disease. If the ex- 
travasation end in the formation of a cyst, the symptoms are those of 
hydrocephalus. The following condensed history of cases which I have 
selected as typical, will give us a clearer idea of the history and course of 
the various forms of meningeal haemorrhage than can be imparted by a 
narration of symptoms : 

M. Tonnele relates the case of a child who was taken with faintness and 



404 INTRACRANIAL HEMORRHAGE. 

convulsive movements. On the following day the trunk and inferior ex- 
tremities became rigid ; deglutition was painful ; the pupils were largely 
dilated, immovable ; face pale ; pulse feeble and intermittent. Death 
occurred the same day. The dura mater was distended. A layer of 
coagulated blood, of great thickness, extended over the convexity of each 
hemisphere. The veins ramifying in the superior portion of the cerebrum 
were distended with coagulated blood. The haemorrhage was in the 
meshes of the pia mater. Drs. Lombard and Panchard, of Geneva, 
relate a somewhat similar case. A child, thirteen months old, was con- 
valescing from inflammation of the bronchial and intestinal mucous sur- 
faces, when it was seized with general convulsions ; the mouth and eyes 
were open, and the eyes directed upward ; pupils contracted ; pulse fre- 
quent and irregular. The convulsions abated somewhat ; but soon reap- 
peared with violence. The patient became insensible, and died nineteen 
hours after the commencement of cerebral symptoms. The extravasated 
blood covered the upper surface of both hemispheres. From the above 
cases we see the symptoms and the course of meningeal haemorrhage, when 
the extravasation is so large that death speedily results. In protracted 
cases of meningeal haemorrhage, there is either a gradual disappearance of 
symptoms and return to health, or, circumscribed hydrocephalus occurring, 
the symptoms of that disease arise. 

Diagnosis. — It is evident, from what has been stated, that the diag- 
nosis of intracranial haemorrhage is attended with unusual difficulty, since 
the symptoms of this disease occur also in other and distinct pathological 
states. The history of the case, and especially the character of the cause, 
if ascertained, will aid in diagnosis. If there have been an obvious deter- 
mination of blood to the brain, or some known obstruction to the return 
of blood from that organ, the persistence of cerebral symptoms would 
justify us in concluding that either serous or sanguineous effusion had 
supervened on a state of congestion. The points of differential diagnosis 
between apoplexy and meningitis are the sudden and full development 
of symptoms in one case, the gradual commencement and gradual increase 
of symptoms in the other ; differences also of symptoms in certain re- 
spects ; for example, as regards febrile reaction, constipation, etc. 

There is one symptom in cerebral haemorrhage which is of great diag- 
nostic value, namely, paralysis. Its presence affords strong evidence that 
there is extravasation of blood, and probably in a cavity in the substance 
of the brain. If the extravasation end in the formation of a cyst, the 
symptoms and appearances of hydrocephalus, which, after a time, arise, 
throw light on the nature of the disease. 

Prognosis. — There can be no doubt that many cases of intracranial 
haemorrhage occur and terminate favorably without the nature of the dis- 
ease being suspected. In such cases the amount of extravasated blood is 
small or moderate. In several published cases in which the accuracy of 



TREATMENT. 405 

the diagnosis was shown by post-mortem examinations, the patients were 
convalescing from the haemorrhage when they succumbed to intercurrent 
diseases. If, however, the amount of extravasated blood be such as to 
give rise to those symptoms which have been described, the prognosis is 
unfavorable. Recurring convulsions, and persistent stupor from which it 
is difficult to arouse the patient, are unfavorable symptoms. If the convul- 
sions cease, and consciousness return, even if there be paralysis, the result 
may be favorable. 

Treatment. — The proper treatment in intracranial haemorrhage de- 
pends on the state of the patient, the time which has elapsed since the ex- 
travasation, and the degree of it, as shown by the nature and severity of 
the symptoms. If, as is often the case, the patient be robust, and be visited 
soon after the commencement of the attack, cold applications should be 
made to the head, mustard to the back of the neck and perhaps chest, and 
derivation should be produced by mustard pediluvia. In many cases, 
especially in active congestion, it is advisable to apply leeches to the tem- 
ples, and the bowels should be opened by a stimulating enema. In active 
congestion, also, prompt purgation by salines or other cathartics is some- 
times of great importance. The object of such treatment is to relieve con- 
gestion of the cerebral and meningeal vessels, and thereby prevent further 
extravasation of blood. If the congestion be active, the pulse continue 
full and frequent, and the face be flushed, it is proper in many cases to 
control the action of the heart by a sedative. For this purpose the tincture 
of aconite root may be given in doses of one drop to a child five years old, 
repeated in three hours if necessary, or veratrum viride may be used. If 
the stupor or convulsions continue after sufficient time have elapsed for the 
patient to receive the full benefit of the above remedies, more active coun- 
ter-irritation is required. Cantharidal collodion should be applied behind 
each ear. If the haemorrhage occur from passive congestion, or in a ca- 
chectic state of system, active depressing remedies should not be employed. 
External derivatives are of service, as well as cool applications to the head, 
and we should attempt, so far as possible, to remove the cause of the con- 
gestion and haemorrhage. If it depend on a cachectic state, tonic or other 
remedies calculated to relieve this state are indicated. The haemorrhage 
from such a cause is apt to be in points in the substance of the brain, or 
in moderate quantity over the surface of this organ, and by a timely use 
of constitutional remedies possibly we may prevent further extravasation 
of blood and increase the chance of the patient's recovery. 

If a cyst result from the haemorrhagic effusion, the treatment which is 
proper is that described in the chapter on Acquired Hydrocephalus. 



406 CONGENITAL II VUKOCEI'H ALL'S. 



CHAPTEU VII. 

CONGENITAL HYDROCEPHALUS. 

Congenital hydrocephalus consists in an excess of the cerebro-spinal 
fluid, lying either external to the brain, or more frequently in its interior. 
It is due to some vice in the development of the brain or its membranes, 
or to a pathological state occurring in them during intra-uterine life. This 
disease is ordinarily apparent from the symptoms and appearances at birth, 
but not always. Occasionally nothing unusual is observed in the shape of 
the head or aspect of the infant till after the lapse of some weeks, when the 
characteristic physiognomy begins to appear. In these cases the disease 
is still congenital, since there is every reason to believe that the abnormal 
state to which the excessive production of fluid is due existed from birth. 
In cases of arrested or partial development of the brain, as, for example, 
when a considerable portion of the hemispheres is absent, there is often an 
unusually large quantity of fluid which serves as a compensation for the 
lack of brain. I do not regard such cases as examples of hydrocephalic 
disease, since the effect of the fluid is not injurious, but rather useful. 
I restrict the term congenital hydrocephalus to those cases in which the 
brain is complete, or, if incomplete, the quantity of fluid is more than 
sufficient to supply the deficiency. 

Anatomical Characters. — According to M. Breschet, the fluid in 
congenital hydrocephalus may be — 1st, between the dura mater and the 
cranium ; 2d, between the dura mater and the parietal arachnoid ; 3d, in 
the cavity of the arachnoid ; 4th, in the ventricles ; 5th, between the 
arachnoid and the brain. 

In a large majority of hydrocephalic patients the seat of the effusion is 
the ventricles. As the quantity of fluid increases, the pressure from with- 
in gradually unfolds the convolutions of the brain, at the same time pro- 
ducing expansion of the cranial arch. When the amount of fluid is con- 
siderable, and it becomes so in the course of a few weeks or months, the 
hemispheres are spread out in a thin lamina on either side, gradually de- 
creasing in thickness from the base of the cranium to the vertex, where 
the brain-substance is sometimes so thin as to be scarcely perceptible. 
Complete absence of brain in this situation, namely, at the vertex, even 
in extreme cases of expansion and flattening of the hemispheres from the 
pressure of the liquid, is rare, though the brain-substance at this point is 
sometimes almost as thin as either of the membranes, so that the wall of 
the sac is translucent. The membranes which surround the brain do not 
usually undergo any alteration, except such as arises from the distension. 



A N A T O M I A L C H A K A C TEKS 



407 



The falx cerebri sometimes disappears, and sometimes the meninges pre- 
sent a whiter hue from maceration than in health. The distension also 
causes such an expansion of the pia mater that it becomes very thin, 
and in places scarcely visible, but its presence in every point can be 
demonstrated. 

The accompanying woodcut represents congenital hydrocephalus as it 
ordinarily occurs. I saw this infant when it was a few days old, and ex- 
amined it from time to time till its death. The parents are healthy and 
have other healthy children. This infant when nine days old began to 

Fig. is. 




liave clonic convulsions of a mild form in the muscles of the face, neck, 
and limbs, which recurred almost daily till the age of six weeks, and 
sometimes every five or ten minutes. When the convulsions ceased in 
the sixth week, the head was observed to enlarge, and its excessive 
growth continued till death, which occurred at the age of seven months 
and one week. While the volume of the head progressively increased, 
the trunk and limbs emaciated. At death the occipitofrontal circum- 
ference of the head was nineteen and a half inches ; the vertical from 
auditory meatus to meatus thirteen and a half inches. 

The changes which the cranial bones undergo, both in their chemical 
character and in their shape, in hydrocephalic patients, if the amount of 
fluid be considerable, are interesting and remarkable. The base of the 
cranium undergoes little change, but those portions of the frontal, parietal, 
and occipital bones which constitute the arch are expanded in all direc- 
tions, while they become much thinner. There is deficiency of lime in 
their constitution, so that the organic elements arc greatly in excess. 



408 CONGENITAL HYDROCEPHALUS. 

This renders them flexible and semi-transparent. Notwithstanding the 
expansion of the bones, there are usually interspaces between them, of 
greater or less size, according to the amount of fluid. 

The scalp, being stretched by the pressure underneath, becomes tense 
and thin, and is scantily covered with hair. The veins which ramify in it 
are unusually prominent and large, and the head is elastic on pressure, from 
the amount of liquid beneath. In the common form of congenital hydro- 
cephalus, namely, that in which the liquid is in the interior of the brain, 
the shape of the orbital plates of the frontal bone is often changed, so that 
the eyeballs have a downward direction. This change in the axis of the eyes 
occurs at an early period, and it continues through the entire disease, be- 
coming more and more marked as the quantity of liquid increases. If the 
amount be large, the lower part of the cornea is buried under the under 
eyelid, while the conjunctiva is visible between the cornea and the upper 
eyelid. The persistent downward direction of the eyes is characteristic 
of this disease, and, in connection with enlargement of the head, is an im- 
portant diagnostic sign. Nevertheless, hydrocephalus even of the ventric- 
ular variety, sometimes occurs without change in the direction of the eyes.. 

If we examine the interior of the cavity after the fluid is evacuated, we 
will find at its base the parts which lie in the floor of the lateral ventri- 
cles, but changed in appearance in consequence of pressure. The cornua 
are enlarged, and the thalami optici and corpora striata are flattened. 
In the early stages of the disease, when the amount of fluid is small, there 
is probably no absorption or destruction of parts in the interior of the 
brain. The various portions of this organ retain nearly their normal 
relation to each other. As the quantity of fluid increases, the foramen 
of Monro, which unites the lateral ventricles, becomes enlarged, the septum 
lucidum which separates them disappears, and the two ventricles form a 
common cavity. In most fatal cases we find this single large cavity. The 
surface which surrounds the cavity occasionally presents a whitish or 
semi-opaque appearance, which has led to the belief, that at a period an- 
tecedent to birth there was subacute inflammation of this surface, and 
hence the effusion. 

The bones of the face are ordinarily less developed than in healthy 
children of the same age, so that the disproportion between the head and 
face becomes a marked peculiarity. The shape of the forehead and face 
is nearly triangular. 

The foregoing remarks in reference to the anatomical characters of con- 
genital hydrocephalus refer in the main to cases which have continued for 
a considerable time, so that their characteristic features are well marked. 
In very young infants, in whom the disease is still recent, similar anatom- 
ical characters are present, but in less degree. 

Congenital hydrocephalus is often associated with other vices of con- 
formation, especially with spina bifida. The two, when coexisting, are 



ANATOMICAL CHARACTERS. 



40£ 



only parts of the same disease ; the large quantity of cerebro-spinal 
fluid preventing the spinal canal from closing during foetal develop- 
ment. 

The fluid in congenital hydrocephalus consists largely of water, in the 
proportion even of 99 parts in 100. In addition to this element, there 
are traces of albumen, chloride of sodium, phosphate and carbonate of 
sodium, and osmazome. 

I have had an opportunity to witness only one post-mortem examination 
in a case of congenital hydrocephalus in which the liquid was exterior to 
the brain. This case was under observation in the children's service of 
Charity Hospital, in 1866. Full notes and measurements of the head 
were taken, which, unfortunately, were mislaid or lost. The infant had 
congenital syphilis, and had a pallid, strumous FlG -^ 

appearance. The shape and relative size of 
the head are seen in the accompanying figure, 
from a photograph. While the whole head 
was enlarged, there was a relative excess of 
development in the part between and above the 
ears. The axis of the eyes was not at all 
changed, and the vision was good. The appear- 
ance corresponded so closely with descriptions 
of hypertrophy of the brain that this was sup- 
posed to be the anatomical state. Antisyph- 
ilitic treatment was employed, and the syphi- 
litic eruptions had nearly disappeared, when 
diarrhoea supervened, followed by death. At the autopsy a quantity 
of transparent or light straw-colored liquid, estimated at six or seven 
ounces, was found exterior to the brain, in the great cavity of the arachnoid, 
lying mostly over the superior surface of the organ. There w r as no excess 
of liquid in the ventricles, and the brain, though of good size, was not 
abnormally large, nor did it possess the firmness which is present in true 
hypertrophy. 

All cases of congenital hydrocephalus may be embraced in two groups, 
namely, that in which the liquid is in the interior of the brain, and that 
in which it lies exterior to the organ. Liquid primarily in the arach- 
noidean cavity permeates the meshes of the pia mater, and lies in part 
underneath it, or this delicate membrane may be ruptured. Four of the 
groups, therefore, described by Breschet, may properly be reduced to 
one, namely, those groups in which the liquid lies under, between, or ex- 
ternal to the meninges. It is probable that some of the cases which led 
to Breschet' s classification were examples of acquired circumscribed 
hydrocephalus, the result of extravasation of blood. In this form of 
hydrocephalus, as is stated elsewhere, an adventitious membrane forms 
external to the liquid, becoming in time thin and delicate, and often bear- 




410 CONGENITAL HYDROCEPHALUS. 

ing a close resemblance to the normal membrane (especially the arachnoid), 
for which it is sometimes mistaken. 

Symptoms. — If there be a considerable amount of hydrocephalic fluid 
prior to the birth of the child, so that the head is abnormally large, partu- 
rition is seriously interfered with. The scalp and meninges may become 
ruptured by the severity of the pains so that the fluid escapes. If this 
do not occur, the labor is often necessarily instrumental. Whether the 
liquid be present before birth or accumulate subsequently to it, the 
tendency is to an increase of the quantity, and a corresponding enlarge- 
ment of the head. 

The digestive function in this disease is at first well performed. The 
infant nurses readily, and has its evacuations with the regularity of other 
children. Not many weeks, however, elapse, in the majority of cases, 
before defective nutrition is apparent. 

While the volume of the head increases, other parts are imperfectly 
nourished and stunted in their growth. Emaciation is common of the 
neck, trunk, and limbs, associated with progressive feebleness. In the 
last stages of this disease there is more or less vomiting, with constipation. 
If there were previously the ability to support the head, it is now lost and 
the erect position is no longer possible. In marked cases, when there is 
great disproportion between the head and the rest of the system, there is 
frequently not even the ability to rotate the head on the pillow. As long 
as the cranial bones yield readily to the pressure from within, and there 
is no compression of the brain, the function of this organ is not seriously 
impaired. The child recognizes its mother or nurse, and it can be amused 
like other children, though easily fatigued. The state of the senses is dif- 
ferent in different cases, and sometimes at different stages of the same 
case. The sight and hearing in some are perfect, in others impaired ; 
while in others still they are good at first, but gradually become obscured 
and lost. It is said that the sense of smell may be perverted, so that 
agreeable odors are unpleasant, and vice versa. Many, reaching the age 
at which children begin to walk, cannot walk, or, if they do, it is with a 
tottering, unsteady gait. 

When the liquid increases to that extent, and it usually does sooner or 
later, that the brain begins to be compressed, dangerous cerebral symp- 
toms arise. The child becomes drowsy, and takes less notice of objects. 
Spasmodic muscular contractions and finally convulsions occur. The pupils 
act feebly or irregularly by light, or one is more dilated than the other. 
Strabismus also occurs. As death approaches, eclampsia, partial or 
general, becomes more frequent, and is succeeded by stupor from which 
the patient cannot be aroused. 

The following case, which I copy from my note-book, is an example of 
the common form of congenital hydrocephalus. It will give an idea of 
the ordinary course of this disease, and show the difficulty which we meet 



SYMPTOMS. 411 

with in its treatment. Female, born November 9th, 1859, with the aid 
of forceps. At birth the fontanelles were unusually large, the cranial 
bones separated, and the aspect in a marked degree hydrocephalic. She 
nursed at first, but, the mother's milk failing, she was afterward bottle- 
fed. At the age of four months her head, which had increased faster than 
her general growth, measured from one auditory meatus to the other, over 
the vertex, seventeen inches ; the occipito-frontal circumference, twenty- 
three inches. At this time she manifested considerable intelligence, being 
able to distinguish her mother from other persons, though the head was so 
large that it was necessary to support it constantly on a pillow. From the 
age of four to six months the operation of tapping was performed six times 
with a small hydrocele trocar, by Prof. Stephen Smith, at a point near 
the coronal suture, and from one inch to one inch and a half from the 
sagittal. At each operation an amount of fluid varying from twelve 
ounces to one pint was removed, and the head then covered with strips of 
adhesive plaster, so as to form a complete cap. It was necessary, how- 
ever, within the twelve hours succeeding each operation, to loosen the 
dressing on account of either the occurrence of convulsions or symptoms 
premonitory of them. The head, within a week subsequently to each 
operation, regained its former size, and, as there was no permanent benefit, 
this treatment was discontinued. She finally died of entero-colitis at the 
age of ten months and five days. 

At the autopsy the distance from one auditory meatus to the other was 
twenty and a quarter inches ; the occipito-frontal circumference, twenty- 
six and a quarter inches. The anterior fontanelle measured antero-pos- 
teriorly four and three-fourths inches ; transversely, seven and three- 
fourths inches. The parietal bones were separated from each other to the 
distance of two or three inches, and they measured in length nine and 
one-half inches. 

On opening the cranial cavity, seven pints, by measurement, of trans- 
parent fluid escaped, exposing a vast open space, at the bottom of which 
were the parts which constitute the floor of the ventricles, somewhat 
changed in shape, and from them, on either side, the hemisphere was 
spread in a lamina, so as to cover the internal surface of the cranial 
bones. The lamina? near the base of the brain measured in thickness 
from half an inch to one inch, and they gradually became thinner on 
approaching the vertex, at which point the brain-substance was exceed- 
ingly thin, so as to be scarcely demonstrable. 

The brain had its normal vascularity and consistence, and the cerebel- 
lum, medulla oblongata, the base of the brain, and cranial nerves presented 
their usual appearance. On folding the brain together, it had the size, shape, 
and aspect of this organ in its ordinary development. Nothing unusual 
was observed in the membranes except their great expansion. The above 
case corresponds in its general features with most cases met in practice. 



412 CONGENITAL HYDROCEPHALUS. 

Diagnosis. — The ordinary form of congenital hydrocephalus, that in 
which the liquid occupies the interior of the brain, can, in most cases, be 
readily diagnosticated. If there be only a moderate amount of liquid, it 
may be confounded with hypertrophy of the brain. In hydrocephalus 
there is commonly more rapid growth and greater expansion of the head ; 
moreover, the enlargement occurs equally on all sides, while in hyper- 
trophy, though all parts of the cranial vault are expanded, the enlarge- 
ment is more at the vertex than elsewhere. The hydrocephalic head 
yields more readily to pressure than the hypertrophied, and often commu- 
nicates a fluctuating sensation. Moreover, in the ordinary form of hydro- 
cephalus, the change in the axis of the eyes described above is an important 
diagnostic sign. In rachitis the volume of the head is often considerably 
enlarged, due sometimes, in part at least, to a deposit of calcareous matter 
on the exterior of the cranial bones. The differential diagnosis is based 
on the shape of the head, round in one, square or with prominences in the 
other, on palpation, direction of the eyes, etc. The smaller the amount 
of liquid, the greater the liability to error of diagnosis ; but if the amount 
be inconsiderable and not increasing, little treatment is required, except 
hygienic and tonic, which is also proper in both hypertrophy and rachitis. 
If the liquid be exterior to the brain, as in the case represented on page 
516, diagnosis may be difficult, but such cases are infrequent. 

Prognosis. — This is unfavorable. The amount of liquid in congeni- 
tal hydrocephalus, as already stated, commonly increases. The most fa- 
vorable result is no increase, or but slight, in the quantity, while the natu- 
ral growth of the infant continues, and thus the disproportion between the 
head and the rest of the system gradually disappears. This result is ex- 
ceptional. Ordinarily, while the quantity of fluid increases, the nutrition 
of the body and limbs is more and more deficient. The patient, if not 
cut off by some intercurrent disease, finally succumbs with cerebral symp- 
toms produced by pressure of the fluid. The majority of those affected 
with congenital hydrocephalus die in infancy, but some enter childhood, 
and occasionally one reaches even adult life. Cases of recovery have been 
reported, but if they were genuine, the disease w T as evidently mild, and 
the amount of liquid small or moderate. 

Treatment. — It is a proper question, in many cases, whether anything 
should be done to relieve the hydrocephalic infant besides attending to its 
general health. The anxiety of parents, however hopeless the nature of 
the case if left to itself, reported recoveries, and the fact that we have 
medicines which in many instances diminish the amount of liquid in the 
internal cavities, incline us to the use of therapeutic measures. 

We may attempt to diminish the quantity of fluid by the use of diuretics. 
Digitalis, squills, nitrate and acetate of potassium, have been used. Prob- 
ably the most efficient diuretic in these cases is iodide of potassium. This 
may be given in doses of one to two grains every two hours to an infant of 



ACQUIRED HYDROCEPHALUS. 413 

six months. Constipation, if present, should be relieved by an occasional 
purgative. If it be tolerated, we may partially prevent the expansion of 
the head by a close-fitting cap. For this purpose strips of adhesive plaster 
about one-third of an inch in width, should be applied so as to cover the 
entire head. The proper way of applying these is as follows : First, one 
strip from each mastoid process to the outer part of the orbit on the oppo- 
site side ; secondly, from the back of the neck, along the longitudinal 
sinus, to the root of the nose ; thirdly, over the whole head, so that the 
different strips will cross each other at the vertex ; and, lastly, a strip long 
enough to pass three times around the head should be applied, passing- 
above the eyebrows, the ears, and below the occipital protuberance. Too 
tight an application should be avoided, as it may give rise to convulsions 
or other cerebral symptoms. If the cap can be tolerated, and the general 
health be good, the prospect is more favorable ; but usually, from the in- 
crease in the quantity of fluid, it is necessary in a few days to remove or 
loosen the plasters in order to prevent convulsions. If this treatment be 
not successful, we may finally resort to tapping. The mode of performing 
this operation has already been indicated in the case which I have detailed. 
No appreciable good result has followed the use of irritating or sorbefa- 
cient applications to the head. Nutritious diet and attention to the gen- 
eral health are requisite. 



CHAPTER YIIL 

ACQUIRED HYDKOCEPHALUS. 

Hydrocephalus, or dropsy of the brain, may also occur in those who 
at birth are well formed and free from disease. Pathologists call this ac- 
quired hydrocephalus. It is in nearly all cases the result of disease, which 
is located sometimes within the cranium, but often in other parts of the 
system. 

Causes. — The diseases within the cranium which most frequently pro- 
duce serous effusion are the meningeal inflammations, both simple and 
tubercular, tumors or other causes which obstruct the venous circulation, 
and hemorrhagic effusion ending in the formation of cysts. Prolonged 
passive congestion often ends in transudation of serum through the coats 
of the capillaries. Therefore, all those causes of congestion, except such 
as have a transient or momentary effect, may be regarded as causes of 
serous effusion. 

Among the diseases external to the cranium which produce serous effu- 
sion within or upon the brain, may be mentioned retropharyngeal abscess, 
tuberculization or inflammation of the bronchial glands, scarlet fever, 
and certain affections of an exhausting nature, especially protracted diar- 



414 ACQUIRED HYDROCEPHALUS. 

rhooal maladies. In at least five cases which have fallen under my notice, 
and in which post-mortem examinations were made, the cause was en- 
larged tubercular bronchial glands, which, by pressure on the venae in- 
nominate, so retarded the flow of blood from the brain as to cause con- 
gestion and effusion. The causative relation of these glands to cerebral con- 
gestion is more fully described in our remarks in reference to this disease. 

Dropsy of the brain is common in protracted infantile diarrhoea, as in 
advanced cases of intestinal catarrh of the summer months in the cities. 
It is preceded and accompanied by passive congestion of the cerebral veins 
and sinuses, due in part to feebleness of circulation in consequence of the 
exhausted state of the patient, and in part to the wasting of the brain, 
which always gives rise to more or less passive congestion, unless in young 
infants, in whom the cranial bones become depressed and override each 
other. Dropsy of the brain resulting from scarlet fever, and that peculiar 
circumscribed dropsy which results from hemorrhagic effusions, are de- 
scribed elsewhere. 

A few cases have been related by different observers, Abercrombie 
among others, in which dropsy of the brain seemed to be essential. Noth- 
ing abnormal was observed, with the exception of serous effusion. But 
the reports of such cases are, for the most part, meagre ; and, as Barrier 
has well said, we are not to accept such cases as examples of essential 
dropsy of the brain, unless the post-mortem inspection be so complete as 
to render it certain that there was no pathological state which might cause 
the dropsy. 

Anatomical Characters. — Acquired hydrocephalus usually occurs 
after the cranial bones are firmly united, and, therefore, the shape of the 
head is not materially altered. If it occur at an early age, before there 
is firm union, there may be expansion of the cranial arch, as we some- 
times observe in the circumscribed hydrocephalus resulting from haemor- 
rhage. The effusion in acquired hydrocephalus occurs over the surface of 
the brain, m the subarachnoid space, or in the lateral ventricles. In the 
dropsy of protracted diarrhoeal maladies, I have rarely failed to find the 
liquid over the whole superior surface of the brain as well as at its base. 

The quantity of fluid in this disease is not large. In the majority of 
cases it does not exceed four ounces, and is often much less. It is trans- 
parent, or it has a slightly yellowish tinge. The membranes of the brain 
sometimes present their normal appearance, but in other cases they are 
injected. The brain itself, in some instances, has an injected appearance 
from passive congestion of the veins and capillaries ; but in others, when 
there has been more or less compression of the brain, there is no more than 
the ordinary, or even less than the ordinary vascularity, and the convolu- 
tions are somewhat flattened. 

Symptoms. — The symptoms of the pathological state, which gives rise 
to the dropsy, precede and accompany those which are referable to the 



SYMPTOMS. 415 

dropsy itself. The dropsy declares itself by symptoms which are alarm- 
ing from the first. 

In children old enough to speak, or manifest intelligence, there may be 
at first complaint of headache. The child is irritable, its mind confused 
or wandering at times, or there is actual delirium. After a time drowsi- 
ness occurs. The head seems too heavy for the body, and is buried in the 
pillow. In fatal cases the features become pallid, the pupils sluggish, and 
perception and consciousness are gradually lost. The child lies in pro- 
found sleep, which increases. There are now often convulsive movements 
partial or general, and these soon end in coma, in which the patient dies. 

The following was an interesting case of acquired hydrocephalus, which 
seemed to result from subacute meningitis. The patient was seen by sev- 
eral physicians, and the diagnosis was for a long time doubtful. 

Harry R. L., of healthy parentage, was well till the summer of 1876, 
when he was nearly at the close of his third year. At this time he was 
observed to be feverish and fretful and his features were flushed at 
times. He also complained almost daily of pain in the top of his head, 
which pain was intermittent, and these attacks of headache occurred for 
at least six months, perhaps longer. There had been no backwardness 
in dentition, and no symptoms of rachitis or struma, and his nutrition 
was good even after the commencement of the present malady. 

In February or March, 1877, his stomach became irritable, so that he 
vomited often during the following months, and about the same time he 
began to lose the use of both legs — a progressive paralysis — and his 
bowels became constipated. Both urination and defecation were slug- 
gishly performed. 

In July, 1877, he ceased to walk, and he has not been able to stand since. 

On March 29, 1878, the following records were made : No improve- 
ment, but gradual increase of most of the symptoms ; lies constantly ; 
moves his limbs slowly, and infrequently, but com- 
pletely, and sensation appears to remain in all of 
them ; his eyes are clear and pupils moderately 
dilated, but without vision — how long his sight is 
lost is not known ; axis of eyes not depressed or 
otherwise changed, and parallelism retained ; the 
cranium, which during the first year of his sick- 
ness underwent little change, has expanded rapidly 
during the last six months ; the enlargement is 
most marked above the ears ; the occipitofrontal circumference is rep- 
resented in the accompanying diagram ; this circumference measures 
twenty-one and a half inches, of which nine and three quarters are in 
front of ears, and eleven and one-third inches posterior to ears ; distance 
over vertex from one auditory meatus to the other, fifteen and one- 
quarter inches. The anterior fontanelle is observed to be open, though 




416 ACQUIRED HYDROCEPHALUS. 

small, the diameter being about one-fourth or one-third of an inch ; 
it is not elevated, and the surrounding edge of bone is flexible. 

This patient lived till near the close of 1880, without material change in 
symptoms, and with moderate but progressive increase in the size of the 
head. At the autopsy measurements were again made, but they have 
been mislaid. The enlargement was found to be due to the presence of 
about three pints of straw-colored serum in the lateral ventricles, which 
had been changed into a large cavity. There was nothing to indicate any 
other disease. From the history and appearances we inferred that the 
hydrocephalus had been due to a mild meningitis occurring in the third 
year. The appearance and state of the encephalon was precisely like that 
in the ordinary congenital hydrocephalus. 

Prognosis. — Acquired hydrocephalus commonly ends unfavorably. 
The prognosis depends not only on the quantity of liquid, but on the na- 
ture of the cause. If the cause be venous obstruction within the cranium 
or thorax, as we have no means of removing it, death is inevitable. If it 
be an exhausting disease, as entero-colitis or scarlet fever, although the 
case is not absolutely hopeless, the prospect is still unfavorable. It is only 
favorable when the quantity of effused fluid is small, the system not much 
reduced, and the primary disease mild. When acquired hydrocephalus 
arises from meningeal apoplexy, the case is apt to be chronic. The symp- 
toms and termination of this form of the disease are very similar to those 
in congenital hydrocephalus. 

Treatment. — The treatment in acquired hydrocephalus must vary 
somewhat in different cases, according to the nature of the disease on 
which it depends. I shall indicate the treatment, in part at least, in the 
description of these diseases. Occasionally the condition of the patient 
is such that there is little to encourage us in the employment of any re- 
medial measures. In vigorous children, if acquired hydrocephalus occur 
in connection with symptoms which indicate too active a circulation, 
moderate abstraction of blood from the temples at an early period may be 
useful, but cases requiring such depletory measures are rare. These cases 
require cold applications to the head ; the bowels should be opened, and 
derivatives should be applied to the feet and back of the neck. 

If the congestion be of a passive character, as when the circulation is 
obstructed by tumors or otherwise, benefit may still be derived from cold 
applications to the head, and derivatives to other parts. In n.ost cases of 
suspected dropsy of the brain, unless the patient be in such a hopeless state 
that all treatment is obviously futile, vesication should be produced behind 
the ears. I prefer cantharidal collodion for this purpose. In addition to 
this treatment, diuretics should be employed, unless there be too great 
prostration, or the course of the disease be so rapid that no benefit can 
result in consequence of the tardy action of these agents. The best diu- 
retics are the acetate of potassium and iodide of potassium. 



MENINGITIS. 417 



CHAPTER IX. 

MENINGITIS, TUBEKCTJLAR AND NON-TTJBEKCULAE. 

The most interesting and important disease of the cerebro-spinal system 
in early life, is that which is now designated meningitis. It is not infre- 
quent. The mortuary statistics of this city show that it is the cause of 
death in from one in twenty-five to one in fifty of the entire number of 
deaths, the proportion varying somewhat in different years. 

In 1768, the attention of the profession was particularly called to this 
disease by Dr. Whytt, of Edinburgh. This observer, and the patholo- 
gists succeeding him, forming their opinion of meningitis from its most 
prominent anatomical character, namely, serous effusion, believed it a 
dropsy. They accordingly designated it acute hydrocephalus. During 
the last thirty years the profession have come to regard the disease as in- 
flammatory, and hence the name by which it is now known, and which is 
believed to express its true pathological character. 

Sometimes meningeal inflammation in children occurs without tubercles. 
In other instances it results from the presence of tubercles, and in most, if 
not in all such patients, there are tubercles in or under the meninges, which 
excite the inflammation in the same manner as in the lungs they cause 
pneumonitis or pleuritis. Therefore two forms of meningitis are recog- 
nized, namely, tubercular and non-tubercular. 

Prior to 1868 I had preserved records of forty-five fatal cases of menin- 
gitis, some occurring in my private practice, and the remainder in insti- 
tutions of this city with which I have been connected. Post-mortem 
examinations were made and recorded in thirteen of them. Twenty -five 
were under the age of one year, of which fifteen were apparently well 
when the meningitis commenced, belonging for the most part to healthy 
families ; three were feeble and cachectic, but apparently without tuber- 
cles ; and five had miliary tubercles in various organs, as shown by post 
mortem examination. The condition of the other two, as regards the 
probable presence of tubercles, was not recorded. 

Of the twenty who were over the age of one year, the majority, 
namely, thirteen, presented a decidedly cachectic or a strumous aspect be- 
fore the meningitis occurred, and a considerable number had symptoms 
of pulmonary tubercles. These statistics, as far as they go, show that non- 
tubercular meningitis predominates under the age of one year, and I may 
add eighteen months, while over that age the tubercular cases are in 
excess. 

M. Bouchut, speaking in reference to tubercular meningitis, says 
27 



418 MENINGITIS. 

as follows : " Up to this period it was not believed that this disease- 
existed in young children, for no mention is made of it in the works of 
Denis and Billard. Still its existence at this age is, nevertheless, incon- 
testable. MM. de Blache, Guersant, Rilliet and Barthez, and Barrier 
have observed several examples of it, and I have collected six cases of 
this disease in the practice of M. Trousseau. The youngest child was 
only three months old, and the eldest had arrived at the end of his sec- 
ond year. No statistics can be based on so small a number of facts ; the 
only value they have consists in their overruling an opinion falsely accred- 
ited in medical science. ' ' I have witnessed the post-mortem of five cases 
of tubercular meningitis occurring in children under the age of one year, 
as is seen from the above statistics, and the age of one of these was only 
four months. In two, perhaps I should say three, of the five the pres- 
ence of tubercles in the meninges was not positively demonstrated ; but 
in all of the five cases miliary tubercles were presen f in the lungs and 
other organs, so that I did not hesitate to consider the meningeal inflam- 
mation of a tubercular character. 

In patients over the age of eighteen months, although the proportion of 
tubercular to non-tubercular cases is larger than under this age, the excess is 
not so great, according to my statistics, as the remarks of some ob- 
servers lead us to suppose. There can be no accurate statistics of 
tubercular meningitis without careful post-mortem examination of the 
state of the brain and other organs in each supposed case, and this exam- 
ination sometimes shows the meningitis to be non-tubercular, when the 
symptoms and signs had indicated its tubercular character. As an exam- 
ple, may be mentioned a case which occurred in the children's service of" 
Charity Hospital, in March, 1868. The infant died at the age of twenty 
months, having had a cough of moderate severity at least three weeks be- 
fore death, and symptoms of meningitis about four days. It was consid- 
erably wasted, and was supposed to have tuberculosis. At the autopsy, 
no tubercles were found in any part of the body, but parts of both Jungs 
were hepatized. A fibrinous deposit, varying in thickness, was found 
over the pons Varolii, the optic commissure, along the fissures of Sylvius, 
over the superior surface of the anterior half and also upon the superior 
lobe of each cerebral hemisphere. As the examination failed to discover 
anv tubercles, the meningitis was considered non-tubercular. Those who 
make these examinations, failing to find tubercles in the lungs and other 
organs in which they usually occur, should examine the lymphatic 
glands, since cheesy glands may be the cause of the formation of tubercles 
in the meninges, while the organs of the trunk remain unaffected. The 
presence of cheesy glands in the absence of visceral tubercles, and with 
granulations upon the meninges, small, covered with fibrin, and of a 
doubtful character, goes far toward establishing the tubercular nature of 
the meningitis. Since the cases which furnished the above statistics were- 



PATHOLOGICAL ANATOMY. ±19 

observed, now more than thirteen years, I have been led by a more 
extended experience, and especially by the observation of cases in the 
New York Foundling Asylum, where there is ample material, to regard not 
only the presence or absence of tubercles, but also of caseous substance, 
as the proper test of the form of meningitis. Not a few that seem at first 
to have non -tubercular meningitis will be found, on more thorough exam- 
ination, to have caseous substance in some part, the result of a pre-existing 
inflammation ; and if we regard the inflammation of the meninges occur- 
ring under such circumstances as tubercular, the relative proportion of 
tubercular cases would be considerably augmented. The following is an 
example : When on duty in the asylum in August, 1881, an infant about 
one year old died of meningitis. No tubercles were observed in the fibrin 
at the base of the brain, and along the fissures of Sylvius but one inflam- 
matory nodule (cerebritis) as large as a chestnut, with suppuration inside, 
was found at the summit of one hemisphere. No tubercles could be de- 
tected in any of the organs of the trunk, unless a few whitish spots in the 
spleen were of this nature, but the bronchial glands were cheesy and soft- 
ened, and the middle lobe of the right lung also contained cheesy sub- 
stance. It seemed to me probable that some of this degenerated product 
taken up by the vessels had lodged in the meninges and produced the 
tubercular neoplasm there, which was hidden under the fibrin. (See article 
Tuberculosis.) 

Age. — The following table gives the age in meningitis, tubercular and 
non-tubercular, in forty-two cases in my collection : 

Cases. Age. 

1 2-£ weeks. (Autopsy.) 

2 . . . . .2 months. 

20 From 3 to 12 months. 

10 "1 year to 2 years. 

5 "2 years to 5 " 

4 Over 5 years. 

42 

Rilliet and Barthez have also published statistics of the age in menin- 
gitis. Their cases were observed chiefly in hospital practice, and the 
result is somewhat different. 

In thirty-two cases of non-tubercular meningitis observed by these 
authors, eight were under the age of one year, six from two years to five, 
and eighteen over the age of five years. In ninety-eight cases of tuber- 
cular meningitis, two were under the age of one year, fifty-one between 
the ages of one year and five, thirty-eight between the ages of five years 
and ten, and seven between ten and fifteen years. 

Pathological Anatomy. — This differs considerably in different cases. 
The dura mater is usually unaffected or is affected secondarily. In many 
cases it retains its normal appearance, its internal surface remaining 



420 M ENINGITIS. 

smooth and polished, while in others it is more or less injected, and its 
internal surface dim or lustreless. The free surface of the pia mater, for- 
merly designated the visceral arachnoid, is in a great part of its extent 
unchanged, but is often hypersemic, or dry and cloudy, or opaque, over 
the seat of the inflammation. Exudation does not occur upon the free 
surface of the pia mater, however intense the inflammation. 

In meningitis, tubercular and non-tubercular, the inflammatory action 
occurs in the pia mater. In its meshes, or underneath them, those lesions 
result which characterize the disease, and to which other lesions are sec- 
ondary. Tubercular meningitis is most frequently basilar, or is basilar 
chiefly and primarily, although the inflammation may extend along the 
sides of the hemispheres. The meningitis is ordinarily most intense 
around the pons Varolii in the subarachnoid space and along the fissures 
of Sylvius, for the tubercular neoplasm occurs chiefly at the base of the 
brain and along the vessels. In non-tubercular meningitis, the inflam- 
mation may also occur at the base. It may in young infants be quite 
diffuse, and of little intensity in any one place, producing, in addition to 
hyperaemia of the pia mater, slight cloudiness and a moderate or slight 
escape of leucocytes from the blood, these (pus-cells) being perhaps visible 
only under the microscope. In meningitis, due to extension of inflamma- 
tion from an otitis media, the inflammatory action is intense, confined to 
the portion of the meninges nearest the ear, and is often attended by in- 
flammation of adjoining brain-substance, with perhaps the formation of 
an abscess. If the cause be exposure to the sun's rays, the meningitis is 
apt to be at the summit of the brain. 

The exudation of fibrin is greatest along the course of the vessels, and 
in the depressions between the convolutions, and the opacity is most 
marked in these situations. Pus, when present, is often semi-solid, from 
the small proportion of liquor puris which it contains, even in recent 
cases. If the disease have continued several days, the liquor puris may be 
mostly absorbed, and the pus-cell becoming shrivelled, irregular, and aggre- 
gated, may resemble closely the cheesy transformation of tubercle-cells. 

The fibrinous exudation presents features of interest. It does not 
usually attain much thickness, but by its opacity it conceals from view the 
brain underneath. If it occur in the fissures of Sylvius, the anterior and 
middle lobes are united by it. It is usually infiltrated through the sub- 
stance of the pia mater. Sometimes little masses of variable size, often 
not as large as a pin's head, appear at the point of inflammation. These 
masses are firm, of a whitish color, or a light yellow, and their number 
varies in different cases. They consist of a firm, homogeneous substance, 
containing granular matter, and cells which often bear a close resem- 
blance to tubercle-corpuscles, but are distinct. These corpuscular bodies 
are plastic nuclei or plastic cells, often shrunken. It is seen, then, that 
there are two morbid products which may be mistaken for tubercle ; one, 



PATHOLOGICAL ANATOMY. ±"21 

pus which lias been in great measure deprived of its liquid element, and 
which may resemble cheesy tubercular matter, the other, plastic nuclei 
collected in little bodies, so as to resemble the ordinary form of crude 
tubercle. I once carried to one of the best microscopists and pathologists 
of this city some of the exudation from a case of meningitis, the cellular 
element in which could not readily be distinguished from shrunken tubercle- 
corpuscles. The exudation was from a child two years and eight months 
old, with good health previously to the meningitis ; without tubercles in 
any part of the body, with parents healthy, and with no predisposition to 
tubercular disease. This microscopist, not knowing the history of the 
case, or character of the family, and ignorant, like all of us at that time, 
of the true tubercle-cell, pronounced the exudation tubercular after a 
careful examination with the microscope. Bouchut says : " The whitish 
miliary granulations which are observed on the surface of the pia mater 
have a certain consistency and tenacity which render them difficult to tear 
with the needles used for the preparation for the microscope. These 
bodies are formed : 1. Of fibro-plastic elements, whether nuclei or fusi- 
form fibres ; oval-shaped cells are generally present, but not always. The 
nuclei are oval or spherical, generally very small — that is to say, they 
hardly exceed in diameter 0.008 mm. to 0.009 mm. The presence of 
these little spherical nuclei must be insisted on, because, with a less power 
than 550 diameters, it would be sometimes impossible to establish the 
ditferences which separate them from the elements of tubercles ; the fusi- 
form fibres are small and rare. 2. There exists a considerable quantity of 
amorphous homogeneous matter, in which minute granulations are scat- 
tered ; it is very dense, and keeps the other elements strongly united to- 
gether, so that it is difficult to isolate them completely. 3. Vessels are 
very rarely observed ; the fibres of cellular tissue are also rare, or alto- 
gether wanting. ' ' 

There being two microscopic elements which are distinct from tubercu- 
lar formations, but are liable to be mistaken for them, namely, shrivelled 
pus-cells and plastic nuclei, more or less altered, it is seen, in part at 
least, why the old waiters, and some of a more recent date, either hold 
that all meningitis is tubercular, or that there are comparatively few non- 
tubercular cases. 

On the other hand, there are cases of true tubercular meningitis which, 
even with a pretty careful microscopic examination, might be, and proba- 
bly often have been, regarded as non-tubercular. In order to an under- 
standing of this subject, I may be permitted to repeat certain facts already 
stated in the article on tuberculosis. The views of pathologists in refer- 
ence to what is the primary form of tubercle, and what is and what is not 
tubercular matter, have recently undergone a great change. It is now r 
known that the tubercle-cell is around, pale, slightly granular cell, identical 
in appearance with the normal cell of the lympathic glands, being in the 



422 M ENING1TIS. 

average somewhat smaller than the white corpuscle of the blood ; that it 
is produced mainly from the nuclei of the connective tissue by prolifera- 
tion ; that it is vitalized like other cells, and, of course, has functional 
activity ; that the true, the living cell, is found only in the so-called gray, 
semi-transparent tubercle. Tt is furthermore known that what has 
heretofore been considered the tubercle-cell, namely, the irregular, some- 
times angular, sometimes oval cell — without, indeed, any typical form — 
may be a dead, shrivelled, and altered tubercle-cell, or a dead, shrivelled, 
and altered pus or other cell. If, therefore, such cells are found in the 
meshes of the pia mater, we cannot determine from the microscope their 
true character. We can only form our opinion in reference to their 
nature from concomitant circumstances, or from discovering in connec- 
tion with them the true tubercle-cell. Those products which have been 
designated crude tubercle and tubercular infiltration, contain these shriv- 
elled cells, or shrivelled nuclei ; and they may have a tubercular origin, 
or, on the other hand, an inflammatory origin, without either the tuber- 
cular product or diathesis. 

In the tuberculosis of young children I have found, in a large propor- 
tion of cases in which I have had an opportunity to make post-mortem 
examinations, miliary tubercles disseminated through the lungs, and per- 
haps other organs, in small masses, many of them not larger than a pin's 
head, and some occurring as mere specks scarcely visible. These minute 
tubercular formations have ordinarily been semi-transparent, and some- 
times even transparent like minute drops of water, and containing the 
true and unchanged tubercle-cell. Now if in such a case meningitis 
occur, we may find the tubercle-cell in or with the fibrin at the base of 
the brain. But failure to find it, even with protracted microscopic exam- 
ination, does not prove its absence from this locality, for I consider it 
almost impossible to discover in the midst of the fibrinous exudation such 
minute points of tubercular matter as are seen in the lungs, liver, or else- 
where. 

The pia mater is often firmly adherent to the brain at the seat of in- 
flammation, so that on raising it a portion of the brain may be detached 
and removed with it. The extent of the inflammation varies much in 
different cases. There may in extreme cases be pretty general inflamma- 
tion of the pia mater. In cases of such extensive meningitis, the symp- 
toms are apt to be severe and the course of the disease rapid. Thus, in 
the month of April, 1866, a girl eleven years of age, in the Protestant 
Episcopal Orphan Asylum of this city, had complained occasionally of 
dizziness, but was otherwise in good health, cheerful, and with excellent 
appetite, till Thursday, when she was affected with vertigo, more persist- 
ent than previously, and with headache. At 2 p.m. on the following 
day she was seized with general convulsions, and continued insensible or 
nearly so, with occasional convulsive movements, till Monday, when she 



PATHOLOGICAL AN A T M V . 423 

died comatose. The pia mater at the vertex, sides, and base of the brain 
had a cloudy appearance, and underneath it, in places, was a thick, 
ereaniy substance in small quantity, which, examined by the microscope, 
proved to be pus, the largest amount being near the pons Varolii. There 
was no tubercle under the meninges or elsewhere, and no appreciable 
fibrinous exudation. The inflammation in this case was obviously intense. 

The only additional lesions noticed were moderate congestion of the 
brain and an increase in the quantity of the cerebro-spinal fluid. 

If the disease be protracted three or four weeks, which is rare, or even 
Jess time, the exuded substance may undergo further changes, such as 
occur in simple exudations in other parts of the system. Thus, on the 
30th of April, I860, we made the post-mortem examination of an infant 
at the Nursery and Child's Hospital, who had symptoms of cerebral dis- 
ease, it was stated, for several weeks, but the exact time was not ascer- 
tained. Prominent among the symptoms referable to the cerebro-spinal 
system toward the close of life were the hydrocephalic cry and rigidity 
of the neck. The appearance at the autopsy was remarkable. The an- 
terior half of the brain was completely encased in a deposit which had 
nearly the appearance of lard. It filled the fissures of Sylvius, and ap- 
peared slightly on the anterior aspect of the cerebellum. Examined 
under the microscope, this substance was found to contain numerous 
cells, among which could be distinguished some resembling pus-cells, but 
nearly all had undergone more or less fatty degeneration. Here and 
there was seen a large cell containing numerous small oil-globules, the 
compound granular cell of pathologists. 

The brain itself in meningitis is usually hypersemic. On making an in- 
cision through it, red points are seen upon the cut surface, which indicate 
the seat of the congested vessels. The inflammation rarely extends to 
the walls of the ventricles, but the choroid plexus is injected. In excep- 
tional instances pus or fibrin is found in the lateral ventricles. In the in- 
fant, two and a half weeks old, whose case has already been alluded to, 
about two ounces of purulent fluid escaped on opening the left ventricle. 
A small amount of liquid of a similar character was contained in the right 
ventricle. The distension of the lateral ventricles with serum is one of 
the common results of meningitis. This fluid is clear or straw-colored, 
or it is turbid in consequence of being mixed more or less with the soft- 
ened brain-substance. The quantity does not exceed two, three, or four 
ounces, and is often not more than one ounce or an ounce and a half. 
The distension of the two ventricles is ordinarily uniform, as they are 
united by the foramen of Monro, but now and then one ventricle is found 
more distended than the other. If there be considerable effusion, the 
brain is compressed and the convolutions have a flattened appearance, un- 
less the cranial bones are still separated so as to yield to the pressure. If 
the sutures and fontanelles be open the cranial arch is expanded, some- 



424 MENINGITIS. 

times quite perceptibly to the eye. From the same cause the anterior 
fontanelle, if open, is elevated. The foramen of Monro is enlarged ac- 
cording to the amount of effusion, and the portions of the brain which 
separate the ventricles are sometimes lacerated. In many cases the 
cerebral substance surrounding the lateral ventricles is softened. The 
softening is found in all degrees, from the least appreciable deviation 
from the normal consistence to a state of diffluence so that the brain pre- 
sents the appearance of cream. Hypotheses have been advanced to ex- 
plain the cause of this change in consistence, which are not entirely satis- 
factory. Whatever the explanation, the fact is attested by all observers, 
though there are exceptional cases. Thus Dr. West has records of the 
condition of the brain in fifty-nine cases, in thirty-seven of which there 
was considerable softening, and in the remaining twenty -two the consis- 
tence w T as normal. 

Since a majority of the cases of meningitis in children are basilar, and 
portions of all the cerebral nerves lie at the base of the brain, it is easy to 
understand why the functions of these nerves are so seriously impaired in 
this disease. Compression of these nerves, or extension of inflammation 
to their sheaths, affords explanation of many of the symptoms, as the 
sighing respiration, abnormalities of the eye, etc. 

Although the above remarks relating to the anatomical characters of 
meningitis are applicable to a large majority of the cases, I must confess 
that I have sometimes been disappointed at the autopsies of young in- 
fants who died with all the symptoms of meningitis in not finding 
more lesions. Moderate hyperemia of the pia mater, its slight opacity 
or cloudiness at the base of the brain or elsewhere, with the presence of 
a few wandering white corpuscles, without any fibrinous exudation, with 
no increase of liquid external to the brain, but a considerable increase of 
it in the lateral ventricles, and hyperemia of the choroid plexus, with 
nearly natural appearance and consistence of the brain, have in some in- 
stances been the only lesions when I had expected to find marked ana- 
tomical changes. 

I am fully convinced from my own observations that, in some in- 
stances, physicians who supposed that they were treating tubercular men- 
ingitis, and at the autopsies discovered within the cranium tubercles, 
without any inflammatory lesion, but with a larger increase of the cere- 
brospinal liquid, have been treating cases in which in addition to the 
meningeal tubercles, which were latent, the bronchial glands were tuber- 
cular and cheesy, so that by their increased size they compressed the 
venae innominata3 within the thorax, thus preventing the free flow of 
blood from the brain, and causing, as I have elsewhere stated, cerebral 
and meningeal congestion, with more or less transudation of serum, but 
with no meningitis. 

Causes. — The causes of non-tubercular meningitis are not fully ascer- 



causes. 425 

tained. Active cerebral congestion frequently occurring, however pro- 
duced, appears to be one of the common causes in young infants. In at least 
three instances I have known meningitis occur in infants between the ages 
of four and eight months, after severe and protracted bronchitis, which 
had been attended with the usual heat of head. The disappearance of 
eruptions upon the scalp, at or immediately before the commencement of 
the meningitis, has often been observed. I have witnessed it at the com- 
mencement of non-tubercular meningitis, as well as of meningitis which, if 
not tubercular, occurred at least in a decidedly scrofulous state of system. 

The direct effect of the solar rays upon the head, and the prolonged 
action of a high atmospheric temperature, even without direct exposure 
of the head to the sun, are common causes during the summer months in 
New York City. I once attended a child with this disease who had been 
much exposed bareheaded to the direct rays of the sun in August and 
September, and at his death, which occurred toward the close of the hot 
weather, found hyperemia, opacity, and fibrinous exudation in the pia 
mater at the summit of the brain, while the base of the brain seemed 
nearly or quite normal. 

In the Jahrbuch f. Kinder •krankh. for October, 1875, Dr. Soltmann, of 
Breslau, reports three cases, in which intense cerebral hyperemia, and 
probably meningitis, occurred from solar heat. In all three children the 
attack was sudden, the febrile movement and heat of head intense, and the 
progress rapid. The first had convulsions, the second automatic move- 
ments, and the third, the oldest, aged four years, when able to speak, 
complained of violent headache. 

The statistics of New York City show that congestive and inflammatory 
maladies of the brain and its covering are more common during July and 
August, which are the months of maximum atmospheric heat, than in 
other months of the year. For example, in July and August, 1875, one 
hundred and sixty-seven died of these maladies, or one in every nine and 
eight-tenths who died from local disease, while during the entire year 
only seven hundred and ten died from the same, or one in every fifteen 
who perished from local diseases. 

July, 1876, in Xew York City, was characterized by excessive and long- 
continued atmospheric heat, the temperature in the Central Park Obser- 
vatory in the shade never falling below 61°, though never above 98°, and 
baring a mean of 82.9°. There was also unusual dryness of the atmos- 
phere, since during the entire month prior to July 30th, there were only 
fourteen hours of rain, with a rain-fall of .77 of an inch, and the average 
atmospheric humidity was represented by 65, saturation being denoted by 
100. During this month I treated in my private practice four fatal cases, 
all between the ages of two and seven years, which I diagnosticated 
meningitis, none of them presenting any symptoms of otitis or tuber- 
culosis. It would seem that the atmospheric heat had much to do with 



42f> MENINGITIS. 

the development of the disease in these cases. One died in two days, but 
in the others there was the usual duration. 

A not infrequent cause, especially among the strumous families of the 
cities, is otitis media, and caries of the petrous portion of the temporal 
bone, the inflammation extending to the meninges. Since tubercular 
meningitis is due to the irritating effect of tubercles in or under the pia 
mater, it usually occurs where tubercles are most abundantly developed, 
that is, at the base of the brain, and along the course of the vessels in the 
inter-gyral spaces. The inflammation is commonly excited when they are 
still small, even minute. 

Premonitory Stage. — Meningitis is usually preceded by symptoms 
which, if rightly interpreted, are of the greatest value. In most cases 
of this malady, which I have seen, there was a prodromic period, vary- 
ing from a few days to several weeks. The symptoms of this period are ob- 
scure, and are apt to be mistaken for* those of other and distinct affections. 

The child in whom meningitis is approaching loses his accustomed 
vivacity and cheerfulness. He has a melancholy and subdued appear- 
ance, being quiet for a few minutes, and then fretful, without apparent 
<;ause. He can sometimes be amused by his playthings or companions 
for a brief period, when he turns from them with evident displeasure. 
Unexpected and loud noises and bright lights are evidently painful. If 
old enough to describe his sensations, he complains of transient dizzi- 
ness, and at other times of headache. His ill-humor, if his wishes are 
not immediately gratified, or if they are denied, is often scarcely endura- 
ble on the part of friends, who are ignorant of the cause. There is great 
•difference, however, in different cases, as regards this symptom. Some 
are inclined to be taciturn and quiet, while others are almost constantly 
fretting. The appetite is capricious ; at one time it is pretty good, at 
another it is poor or even entirely lost. The patient may take a few 
mouthfuls of food, or, if an infant, nurse for a moment, when his hunger 
appears satisfied, and he will take nothing more. The bowels are regular 
or inclined to constipation. The pulse is natural, or it has times of accel- 
eration, especially in the latter part of the day and toward the close of the 
premonitory stage. The duration of this stage is very different in differ- 
ent cases. Upon an average it is perhaps about two weeks, but it is often 
longer. In tubercular meningitis the symptoms, both during the inflam- 
mation and previously, are apt to be complicated by those which arise 
from tubercles in other parts of the system. 

Unless the prodromic period be of short duration, the effect of imper- 
fect nutrition is obvious before it closes. The flesh becomes soft and 
flabby, or there is actual emaciation, though generally slight. The pa- 
tient loses his strength, becoming less able to stand or to walk, and more 
easily fatigued. Occasionally, especially in the non-tubercular form, pre- 
monitory symptoms are absent, or are slight and of short duration. 



S Y M P T O M S . 427 

Symptoms. — Dr. Whytt, living in the last century, when the tendency 
was toward refinement rather than simplicity in classification, divided 
meningitis into three stages, according to the symptoms, especially the 
pulse. Many subsequent writers, following Whytt* s example, have rec- 
ognized three stages, based not upon the anatomical characters of the 
disease, but upon the succession of symptoms. Such division of menin- 
gitis is in great measure arbitrary, since in one case the same symptom 
occurs at an earlier period than in another. 

When the premonitory stage has passed, and inflammation is developed, 
some of the symptoms which were previously present remain and are in- 
tensified, and other new and more characteristic symptoms appear. There 
are now fewer intervals of apparent improvement. The child is quiet, 
often lying with his eyes shut. If aroused, he has a wild expression of 
the face, and is irritated by attempts to engage his attention or amuse 
him. He rarely smiles, or takes his playthings, or he notices them for a 
moment, when he turns away with disgust. During sleep there is often 
at first a placid expression of countenance, but when aroused he has the 
aspect of real sickness ; the eyebrows are sometimes contracted, as if from 
headache ; the features wear a melancholy look, and are turned away to 
avoid the gaze of the observer or to shun the light. If the anterior fon- 
tanelle be open, it is observed to be prominent and pulsating forcibly. If 
consciousness be not lost, and the patient be of sufficient age, he com- 
plains of headache, or of pain in some part of the body. The tongue is 
moist, and covered with a light fur ; the appetite is lost or poor ; there 
is seldom much thirst ; more or less nausea and constipation are present. 
As the inflammation continues, and usually within three or four days 
from its commencement, symptoms arise which dispel all doubts, if there 
were any, as to the nature of the disease. The vital powers are now evi- 
dently beginning to yield. The surface generally is more pallid, and there 
is the curious phenomenon of the sudden appearance, and, after some 
minutes, disappearance, of spots or patches, or even streaks of active con- 
gestion upon the face, forehead, or the ears. These, having a bright red 
color, contrast strongly with the general pallor. Ordinarily they are 
irregularly circular or oval, and from one inch to an inch and a half in 
diameter. A red spot or streak is also produced if the finger be pressed 
upon the surface or drawn forcibly across it. It continues a few minutes 
and then gradually fades. Trousseau calls attention to this fact as a diag- 
nostic sign. 

Another curious phenomenon is the variation in temperature. The face 
and limbs at one time feel quite cool, and after some minutes, without 
any excitement or other appreciable cause, the temperature rises, so that 
the surface is warm to the touch. 

Consciousness, in severe cases, may be lost at an early period. On 
the other hand, I have known it in a case of moderate severity to remain, 



428 MENINGITIS. 

though partially obscured, till within twenty-four or thirty-six hours of 
death. The patient will usually open his mouth for drinks, which are 
placed to his lip, when there is no other evidence of intelligence, and 
when sight and hearing are evidently lost. 

The loss of the senses constitutes an interesting but melancholy fea- 
ture of the disease. Among the first unequivocal symptoms, and fre- 
quently the very first, are such as pertain to the eye. This organ should 
be watched from day to day when the diagnosis is uncertain. Deviation 
from its normal state affords evidence of meningitis. The pupils are seen 
to dilate or contract sluggishly by variations in the intensity of the light, 
or they are not of the same size with those of another individual to whom 
the same amount of light is admitted. Sometimes the first perceptible 
deviation from the normal state is an inequality in the size of the pupils ; 
while in others oscillation of the iris is observed. At a later stage, not 
generally till convulsions have occurred, the parallelism of the eyes is lost, 
and in most patients they have an upward direction. After effusion has 
occurred, the pupils are commonly dilated. As death approaches, the 
eyes become bleared, and a puriform secretion collects in the inner angle 
of the eye and between the eyelids. This secretion is not abundant, but 
it is sometimes sufficient to unite the lids. The sense of hearing is prob- 
ably lost as soon, or nearly as soon, as that of sight, but the sense of 
touch continues longer. The tongue is covered with a moist fur, unless 
near the close of life, when it is sometimes dry. The appetite is grad- 
ually lost, but often drinks are taken with apparent relish, even when 
there is no other evidence of consciousness. There are two symptoms 
pertaining to the digestive system which are rarely absent, and which 
possess great diagnostic value ; one is vomiting, the other constipation, 
In some patients, irritability of stomach begins at so early a period that 
it is really prodromic ; it is rarely absent. Barrier collected the records 
of eighty patients with meningitis, and in seventy-five of these this symp- 
tom was present. It is due to the intimate relation existing between the 
stomach and brain, through the ganglionic system of nerves. The vom- 
iting occurs without effort, and usually at intervals, for several days. It 
is a sudden ejection of the contents of the stomach, apparently without 
preceding or subsequent nausea. It contrasts, therefore, with the vom- 
iting due to an emetic, which is attended by distressing symptoms. 
With some it occurs frequently, with others not more than two or three 
times daily. Commencing in the first stages of meningitis, or even prior 
to it, it occurs less often as the drowsiness becomes more profound, and 
finally ceases. Constipation is also present, usually from the commence- 
ment of the meningitis. It is one of the most constant and persistent 
symptoms, continuing through the entire sickness, unless relieved by 
medicine, or unless there be a coexisting diarrhoea! affection. Often, when 
diarrhoea precedes the meningitis, it ceases the moment the latter com- 



SYMPTOMS. 429 

mences. The constipation in this disease is easily overcome by purga- 
tives. Several writers speak of retraction of the abdomen as a sign of 
meningitis. A hollow or sunken appearance of the abdomen, according 
to Golis, aids in distinguishing meningitis from fever. The anterior ab- 
dominal wall approaches the spine, so that the pulsations of the abdomi- 
nal aorta are distinctly felt. Rilliet and Barthez, who have rarely ob- 
served this retraction except in cerebral diseases, attribute it to the state 
of the intestines rather than to the action of the abdominal muscles. 

The pulse in the first stages of meningitis is accelerated, or it is nearly 
natural during certain hours and afterward accelerated. When the dis- 
ease has continued a few days, often not more than three or four, the 
pulse undergoes a marked change. It becomes slower, and at the same 
time irregular. The irregularity usually consists in an intermittence of 
the pulse after each six or eight beats. Sometimes the force of the pulse 
varies, so that a feeble pulsation is succeeded by one of greater volume 
and strength. The decrease in the frequency of the pulse cannot fail to 
arrest attention. From 110 or 120 beats per minute in the first stage of 
the inflammation it often descends to a frequency even less than the nor- 
mal adult pulse. At an advanced period, as death approaches, the pulse 
again becomes accelerated and feeble. 

The change in respiration is as decided as that of the pulse. In the 
beginning of the meningitis respiration is sometimes moderately acceler- 
ated, but in other cases it is natural. When the disease has continued a 
few days, the time usually varying from three or four to more than a 
week, a marked alteration occurs in the respiratory movements. Their 
rhythm, like that of the pulse, is disturbed. The breathing is irregular, 
intermittent, and accompanied by sighs. This change in pulse and res- 
piration corresponds with the loss of consciousness, and shows that the 
brain is becoming seriously involved. 

When the pulse and respiration undergo the changes which have been 
described, another prominent and grave cerebral symptom is often pres- 
ent, namely, convulsions. Its occurrence diminishes greatly the prospect 
of a favorable issue. The severity and extent of the convulsive move- 
ments vary in different cases. They may be partial or general. Their 
duration is often brief, but they recur three or four times through the 
day. They are preceded by cephalalgia in those old enough to express 
their sensations, and often by drowsiness. Each convulsive attack ends in 
still greater drowsiness. 

With this group of symptoms another should be mentioned. I refer to 
the hydrocephalic cry. At intervals the patient, without being disturbed, 
and without any change in symptoms, utters a scream or sharp cry, and 
immediately relapses into his former state. This cry is more common in 
the commencement of the meningitis than subsequently, and in many it 
is absent or is not a marked symptom. The glandular system participates 



430 MENINGITIS. 

in the general loss or derangement of function. Tears are seldom shed,- 
even when the child is much irritated, and the urinary secretion is di- 
minished. The small amount of urine passed sustains an important rela- 
tion to the progress of the disease and the therapeutics. 

The patient usually lingers several days after the pulse and respiration 
are changed in the manner stated. The drowsiness becomes more pro- 
found, the vomiting ceases, as well as the convulsive attacks, and sensa- 
tion and consciousness are entirely lost. But even in this state, if nutri- 
ment and stimulants be administered with regularity, the child often 
lives several days longer than the friends believed to be possible. At 
length increasing feebleness and rapidity of pulse and coldness of the 
face and limbs indicate the near approach of death, which occurs in a state 
of coma. 

The symptoms described above are such as we observe in ordinary cases 
of meningitis, and in the order which I have indicated. But he will be 
disappointed who expects that the above description will apply to all 
cases. 

Meningitis may be so violent and rapid that both the character and 
succession of symptoms are different from those which have been stated, 
Thus, I have related the case of a girl, who, with no prodromic symp- 
toms excepting occasional dizziness and slight headache, was taken sick on 
Thursday, had convulsions on Friday, and from this time continued 
either in convulsions or coma till her death on Monday. Again, even in 
cases of the usual duration and anatomical character, some of the most 
prominent symptoms upon which we rely for diagnosis may be lackingv 
The following was a case of this kind : 

Case. — On the 5th of April, 1862, I was asked to see a boy two years 
and eight months old, of healthy parentage, and who, during the preced- 
ing year, had been in uniform good health, but previously had had two> 
or three severe attacks of sickness. His head w r as unusually large, and 
whenever much indisposed he often had symptoms premonitory of con- 
vulsions, which were always, however, prevented. 

One night, in the latter part of March, his parents noticed that his- 
sleep was restless, but on the following day he seemed entirely well, and 
the restlessness at night was attributed to a late and hearty supper. On 
succeeding nights, however, he was restless, and, when questioned, com- 
plained of pain in the abdomen. In a few days he was observed to be 
drooping in the daytime, and his appetite was not quite so good as pre- 
viously. He had continued in this way about a week when my first visit 
was made. 

The abdominal pain had at this time become more constant, but was 
never severe or accompanied by moaning. When asked where he felt 
sick, he placed his hand upon the epigastrium, pressure upon which was 
sometimes tolerated, but at other times painful. The following symp- 
toms were noted : tongue slightly furred, anorexia, thirst, constipation, 
scantiness of urine, no headache or unusual heat of head during any part 
of his sickness. He vomited at intervals from about the 7th to the 10th 



DIAGNOSIS. ±31 

of April, when the irritability of stomach ceased, and there was no return: 
of this symptom. 

About April 7th, the respiration was first observed to be irregular and 
sighing, and the pulse intermittent. These symptoms, so tardily de- 
veloped, were the first which indicated cerebral disease. He now lay most 
of the time in bed, with eyes closed, surface commonly pallid, with occa- 
sional rose-colored spots or patches upon the cheek or forehead. The 
pupils responded to light in the usual manner till near the close of life, 
but bright lights were painful ; the last two or three days of his life the 
left pupil was more dilated than the right. He had no convulsions or any 
spasmodic movement, and was conscious till within a few hours of death ; 
the mother states that there was unequivocal evidence of his recognition 
of her on the last day of his life. He died April 17th, nearly three weeks 
after the commencement of the disease, and fen days after the commence- 
ment of symptoms which were distinctly referable to the brain. 

Autopsy. — Abdominal organs healthy, though epigastric pain had been 
so constant and prominent a symptom ; brain and its membranes some- 
what injected. The meninges covering the base of the brain from the 
most prominent part of the pons Varolii to the first pair of nerves pre- 
sented evidences of inflammation. There was such opacity of the pia 
mater in places as to conceal the brain from view. The anterior and 
middle lobes of each hemisphere were glued together by fibrinous exuda- 
tion, and on the left side, along the fissure of Sylvius, was a thick de- 
posit of the same character. The lateral ventricles contained about an 
ounce of clear serum, and about half an ounce escaped from the base of 
the brain. The foramen of Monro was considerably enlarged, and the 
brain -substance surrounding the lateral ventricles was somewhat softened, 
but not in a notable degree. 

In this case it is seen that the prominent symptom, and, indeed, almost 
the only marked symptom in the first stages of the disease, was pain in 
the abdomen, and yet the abdominal organs w T ere healthy. At the very 
moment when it was highly important that a correct diagnosis should be 
made, the evidences of cerebral disease were lacking. This case is, there- 
fore, interesting on account of the variation in symptoms from those in 
the usual form of meningitis. There were no convulsions, and conscious- 
ness was retained as well as vision till near the close of life, and yet the 
lesions were such as are commonly present in meningeal inflammation. It 
is in such cases that a wrong diagnosis is apt to be made, to the injury of 
the patient and the reputation of the physician. 

Occasionally meningitis may continue so long as to almost justify its 
being called chronic, even when there is a large amount of exudation 
upon the pia mater. In the few cases which end favorably, the symp- 
toms abate gradually. T shall describe more fully the termination in 
speaking of prognosis. 

Diagnosis. — It is of the utmost importance to diagnosticate menin- 
gitis in its first stages, since treatment, to be successful, must be com- 
menced early. Certain writers describe at length the means of diagnos- 
ticating the simple from the tubercular form of the inflammation. Differ- 



432 MENINGITIS. 

ential diagnosis is often difficult, and sometimes impossible ; but it mat- 
ters little, practically, whether the form of the disease be ascertained. On 
the other hand, it is very important, in order that the treatment be ap- 
propriate, to diagnosticate the premonitory or initial stage of meningitis 
from certain other affections not located within the cranium. Sometimes 
remittent or continued fever, or constitutional disturbances arising from 
irritation in the digestive system, simulate closely incipient meningeal dis- 
ease, so that the greatest care and discrimination are required in order to 
make a correct diagnosis. Within a comparatively recent period I have 
known, in three different instances, experienced physicians of this city 
mistake commencing meningitis for fevers, not aware of the serious error 
they had made till the inflammation had reached a stage from which re- 
covery was impossible. In order to avoid error in the diagnosis in the 
premonitory or initial stage of meningitis, the physician should take time 
to observe the physiognomy, and note every symptom. More than one 
protracted visit is often required to remove doubt as to the exact patho- 
logical state. 

Meningitis is usually preceded and in its commencement accompanied 
by greater restlessness, fretfulness, intolerance of light, and greater varia- 
tion of symptoms than most other maladies. One familiar with the phys- 
iognomy of infancy and childhood, will discover in the features indica- 
tion of greater suffering, of more serious sickness, than is commonly 
present in other maladies which simulate this. 

Sometimes the sudden disappearance of a chronic eruption upon the 
scalp will aid in the diagnosis. This is a sign of importance, taken in 
connection with the symptoms. Headache and vomiting, symptoms of 
early occurrence, should especially arrest attention, or, in absence of head- 
ache, pain of a neuralgic character in some other part. But we may re- 
peat that familiarity with the symptoms of meningitis will not protect 
from error if the visits of the physician are hasty, and his examinations 
imperfect. When the eyes become affected, the respiration and circula- 
tion irregular, and especially when convulsive attacks begin, diagnosis is 
easy. In fact, an incorrect diagnosis would then be unpardonable ; but, 
unfortunately, if proper treatment have not been commenced till this period, 
it will be of little service. 

Prognosis. — Meningitis is one of the most fatal maladies of early life. 
Whether the form be tubercular or not, if the initial stage have passed 
without proper treatment, death may be considered inevitable. Tuber- 
cular meningitis, however early recognized, is rarely amenable to treat- 
ment. M. Guersant {Die. Med., t. xix., p. 403) believes that recovery 
from the first stage of this form of meningitis is possible. " In the sec- 
ond stage," says he, "I have not seen one child recover out of a hun- 
dred, and even those who seemed to have recovered have either sunk after- 
ward under a return of the same disease in its acute form, or have died of 



PROGNOSIS. 433 

phthisis. As to patients in whom the disease has reached its third stage, 
I have never seen them improve even for a moment." The very few re- 
ported cases which resulted favorably may have been, as M. Guersant has 
intimated in the context, cases of the non-tubercular form. Rilliet and 
Barthez believe that in a few instances tubercular meningitis has been 
cured in its first stage, but they state also that it is apt to return. 

The prognosis in non-tubercular meningitis is not so unfavorable, pro- 
vided that treatment be commenced at a sufficiently early period. It is now 
generally admitted that it may not infrequently be averted, when threat- 
ening, and even arrested in its incipiency. In many such cases we can- 
not, from the nature of the disease, be certain that the diagnosis is correct. 
But when we see children relieved, who present precisely those premoni- 
tory and even initial symptoms which occur in meningitis, we must be- 
lieve that at least some of them would have had the genuine disease if not 
relieved by the measures employed. That recovery is possible from 
non-tubercular meningitis in its commencement, is also obvious from the 
fact that a few recover even in the second stage, when there can be no 
error of diagnosis. 

Although a considerable proportion of patients with epidemic cerebro- 
spinal meningitis recover, even when the symptoms have been most grave, 
I have known only two recoveries from sporadic meningitis when it had 
reached that stage in which the functions of the brain and cranial nerves 
were impaired. One of these recovered with the permanent loss of sight, 
the other with the loss of hearing. Both seem to have ordinary intelli- 
gence. Another case has been communicated to me, in which the pa- 
tient, a little girl, recovered completely, but for several months after the 
attack seemed nearly idiotic. 

Sometimes even in the second stage of meningitis, treatment properly 
employed is attended by amelioration of symptoms. Though such im- 
provement may serve to encourage physician and friends, it should not 
be the basis for a favorable prognosis unless it continue three or four days. 

Apparent improvement during a few hours or a considerable part of a 
day, is not unusual in those who finally die. Thus, in an infant whose 
bowels were previously confined, I have known the pulse and respiration 
to become more regular and the symptoms generally improve, though 
only for a brief period, by the action of a purgative. Dr. Watson says 
of the advanced stages of this disease, it is " often attended with remis- 
sions, sometimes sudden, and sometimes gradual, deceitful appearances of 
convalescence. The child regains the use of its senses, recognizes those 
about him again, appears to his anxious parents to be recovering, but in 
a day or two it relapses into a state of deeper coma than before. And 
these fallacious symptoms of improvement may occur more than 
once." 

Most fatal cases of meningitis terminate between the third or fourth 
33 



434 MENINGITIS. 

and the twentieth day, the duration varying according to the extent and 
intensity of the inflammation, and the vigor and age of the patient. But 
there are cases in which it may continue much longer. It is surprising 
sometimes how long the patient lives, when the symptoms are such that 
death seems impending. Sensation and consciousness may be extin- 
guished, convulsions occur at intervals, and the surface have acquired 
almost a cadaveric aspect, and yet the patient lives on. Rilliet and Bar- 
thez say : " Often have we inscribed upon our notes death imminent, and 
been astonished the next day to find still alive children to whom we had 
scarcely allowed two hours of life." The symptom which I have found 
to be the most reliable prognostic of the near approach of death, has been 
a pulse gradually becoming more frequent and feeble, though other symp- 
toms remain as before. This change in the pulse is usually very apparent 
during the last twenty-four hours of life. 

Treatment. — Such remedial measures should be prescribed during the 
premonitory stage as are calculated to relieve the fretfulness or irritability 
of temper and quiet the action of the brain, and, at the same time, pro- 
duce a derivative effect from this organ. To this end the patient should 
be kept from all causes of excitement, and the bowels should be opened 
daily, if not naturally, by the use of proper medicines. A mustard foot- 
bath at night and occasionally through the day is useful, as it produces 
both a derivative and soothing effect. It will commonly produce a few^, 
hours' undisturbed rest, while all other measures except medicine fail. If 
dentition be taking place, and the gums are swollen, it has been the prac- 
tice to employ the gum lancet, and still is with some physicians, but I for 
one have discarded its use for this purpose. Restlessness from dentition 
or restlessness premonitory of meningitis, requires decided doses of bro- 
mide of potassium, which will relieve the symptoms more effectually than 
the lancet. Three grains should be given to a child of six months, and 
four grains to one of ten or twelve months, and repeated if necessary in 
two to four hours. If symptoms indicate the near approach of menin- 
gitis, or its incipiency, the head should be kept constantly cool by a cloth 
wrung out of ice-water, or, better, an india-rubber bag containing ice, and 
cantharidal collodion should perhaps be applied behind one or both ears, 
over a space one inch in diameter. 

Many children who are threatened with meningitis are scrofulous. 
They have already shown symptoms of tubercular disease. They are, per- 
haps, to a certain extent, emaciated, and may have been affected with a 
cough. The premonitory symptoms in these children indicate the ap- 
proach of the tubercular form of meningitis, and a more sustaining course 
of treatment is required than in those who are robust. To such children 
cod-liver oil may be profitably given, three times daily, together with the 
syrup of the iodide of iron, and perhaps the bromide. They should also 
be taken into the open air, with proper precautions, and every hygienic 



TREATMENT T . 435 

measure should be employed which will he likely to invigorate the system 
without exciting the brain. 

Loss of blood is not, in general, required during the prodromic period 
nor in the disease. Those of a strumous cachexia, or those, whether 
strumous or not, who are under the age of two years, do not, unless in 
very rare instances, require depletion by leeches, much less by venesec- 
tion. There is one class of patients in whom the early loss of blood may 
doubtless be of service, namely, those who in a state of robust health are 
suddenly seized with inflammation. Leeches may then be applied to 
the head of the patient, if he be seen at an early period. 

Often, notwithstanding the measures employed, the patient grows 
worse, the symptoms become more continuous, others more alarming 
arise, and meningitis declares itself. Whatever the cause of the inflam- 
mation, and whatever modifications of treatment were required in the 
premonitory stage, on account of special indications, the purpose now is 
to subdue the inflammation by every resource in our art, which does not 
injure or too much prostrate the system. In former days calomel was 
largely employed as the main remedy in this disease, but when adminis- 
tered daily it has a very depressing effect, and it is to be borne in mind 
that in meningitis the vital powers progressively fail on account of the 
loss of appetite, vomiting, etc. In tubercular meningitis depressing 
treatment is, of course, strongly contraindicated, cases having occurred in 
which calomel was given at short intervals for several successive days, so 
as to produce a laxative effect, and though the meningitis seemed to be 
controlled, death occurred from exhaustion, or from some intercurrent 
affection, the result of the exhaustion. Thus in one case related to the 
class by a distinguished professor in New York City, fatal gangrene of the 
mouth supervened from the mercurial treatment, after the meningeal in- 
flammation had apparently subsided. Although calomel, during these 
last years, has been properly discarded as the main remedy, and its daily 
use rejected, nevertheless it is very useful as an occasional laxative in the 
more robust cases, if not given too near the iodide of potassium, and it 
is especially indicated as a derivative from the head in children of four or 
five years, w r ho, previously hearty and strong, have become suddenly 
affected with meningitis, as from exposure to the sun's rays, or from an 
injur}'. But I repeat that, in my opinion, in ordinary cases, calomel 
should never be employed, except as an occasional laxative. 

The two remedies upon which we must chiefly rely are the iodide of 
potassium and the bromide of potassium, or sodium. "While the bro- 
mide quiets the restlessness, prevents convulsions, and diminishes, there 
is reason to think, to a certain extent, the hyperaemia, the iodide is use- 
ful as a sorbefacient, and it probably has some control over the inflamma- 
tion. The iodide or bromide can be given together or separately. 

The iodide should, like the bromide, be given earlv. If bv a careful 



436 M E N I N G I T 1 S . 

examination, the absence of any other local disease, or constitutional dis- 
ease, which might give rise to the symptoms be ascertained, and the 
symptoms indicate the meningeal disease, the iodide should be immedi- 
ately prescribed. Obscurity often hangs over meningitis at this early 
stage, but it is better to give the iodide, even if the diagnosis be wrong, 
and no inflammation have commenced, than to err on the other side, and 
withhold it in the initial period of the true disease, for it is not an inju- 
rious remedy like calomel, and to exert any marked curatire effect it 
should be given in the commencement of the inflammation. An infant of 
the age of six to twelve months should take two grains every two hours, 
and older children a proportionate dose. At the same time the bromide 
should be given in doses twice as large as that of the iodide, if the indica- 
tions for its use are present, namely, headache, restlessness, and symp- 
toms which threaten eclampsia. The bromide is a harmless remedy given 
frequently for a limited time. With the regular and continued use of 
the iodide and occasional doses of the bromide, the quantity of urine is 
in most cases largely increased. If the patient's condition do not soon 
begin to improve with such treatment there is no remedy. 

If convulsions occur the bromide should be given every ten or fifteen 
minutes till they cease. If they be not controlled by the bromide, an 
injection, per rectum, of three to five grains of hydrate of chloral in a 
teaspoonful of water should be used in addition. Compresses wrung out 
of cold water frequently applied to the head, or a bladder containing 
pounded ice, and separated by one thickness of muslin from the head, 
materially aids in reducing the meningeal hypersemia. Ergot, recommend- 
ed by Brown-Sequard for its supposed effect in diminishing the hyperse- 
mia in myelitis and spinal meningitis, has also been employed as an ad- 
juvant in the treatment of inflammation of the meninges of the brain. I 
have prescribed it in a few instances, bat cannot say whether it is useful. 
I prescribed it in nearly all the cases of epidemic cerebro-spinal menin- 
gitis which I saw during the epidemic of 1880-81, but in these cases the 
spinal disease was present which seemed to require this agent. 

In the first stage of simple meningitis the diet should be mild and in 
moderate quantity, but in the tubercular form it should from the first be 
of the most nourishing kind, consisting of beef-tea, milk-porridge, 
etc. At a more advanced stage in both forms of the malady the most 
nutritious diet should be allowed, but alcoholic stimulants should not be 
given unless near the close of life when the vital powers are failing. The 
apartment should be cool and quiet. 



SPURIOUS HYDROCEPHALUS. 437 



CHAPTER X. 

SPURIOUS HYDROCEPHALUS. 

The disease known as spurious hydrocephalus might with more pro- 
priety be called spurious meningitis. It received its appellation at the 
time when meningitis of early life was believed to be essentially a hydro- 
cephalus, and was so called. Attention was first directed to this malady 
by London physicians of the last generation, particularly by Drs. Gooch, 
Abercrombie, and Marshall Hall, and little can be added to their descrip- 
tion of its symptoms. 

Anatomical Characters. — This disease, though resembling menin- 
gitis in certain of its phenomena, is not in its nature inflammatory, nor is 
it primary. It is the result of some malady often chronic, but occasion- 
ally acute, which has produced exhaustion, especially of the nervous sys- 
tem. When it commences, there is usually more or less emaciation, and 
the symptoms of the primary disease are present. To this disease the 
lesions pertain which are found in other organs beside the brain. 

The state of the brain in spurious hydrocephalus is not the same in all 
cases. In some there is no appreciable anatomical alteration in this 
organ. There is no apparent difference, either in the meninges or the 
brain itself, from the condition which we often observe in those who 
have died of diseases which do not affect the cerebro-spinal system. In 
such cases the pathological state is simply deficient innervation, or if there 
be a structural change in the minute anatomy of the brain, pathologists 
have not yet discovered it. 

The following case, which occurred in the Child's Hospital of this 
city, is an example of this form of spurious hydrocephalus : 

Case. — A female infant, six months old, died on the 24th day of 
April, 1862, with the following history : It was wet-nursed, fleshy, and 
apparently well, till six days before death, when symptoms of gastro- 
intestinal inflammation were suddenly developed. The vomiting, espe- 
cially, was severe, continuing forty-eight hours. When it ceased, drow- 
siness supervened, and continued till the close of life. The face during 
the four days of stupor was pallid and cool ; eyes partly open, pupils 
sluggish, but of equal size ; bowels rather torpid ; anterior fontanelle de- 
pressed. When aroused, the infant noticed objects for a moment, and 
immediately relapsed into sleep ; pulse accelerated and not intermittent, 
the day before death numbering one hundred and fifty ; respiration accel- 
erated, without sighing, numbering on the same day thirty. There were 
no convulsions, and death occurred quietly. The brain weighed twenty 
and a half ounces, and its appearance was perfectly healthy, both as 
regards consistence and vascularity. The amount of cerebro-spinal fluid 



438 SPURIOUS HYDROCEPHALUS. 

in the ventricles and at the base of the brain was not notably increased. 
The stomach, small and large intestines, were vascular in streaks and 
patches. 

In this case the cerebral symptoms were obviously due to exhaustion 
occurring at an early period, in consequence of the severity of the gastro- 
intestinal malady. 

In a majority of cases, however, of spurious hydrocephalus, according 
to my observation, there is an anatomical alteration in the state of the 
brain and meninges. This consists in passive congestion of the veins, 
often with transudation of serum. At the same time the cranial sinuses 
are congested, and are found at the post-mortem examination to contain 
larger and more numerous clots than are present in those who die of dis- 
eases which do not affect the encephalon. Cases might be cited as exam- 
ples. The cause of this congestion and effusion is, in great measure, fee- 
bleness of the circulation due to the general exhaustion of the patient. 
But there is another cause. In protracted diseases, especially those of a 
diarrhceal character, there is more or less wasting of the brain as well as 
of other parts. This naturally, by way of compensation, gives rise to 
congestion of the cerebral and meningeal veins and capillaries and to 
transudation of serum. 

The transudation commonly occurs in this malady over the superior 
surface of the brain and in the subarachnoidal space, perhaps also more 
or less in the lateral ventricles. So common is it in the last stage of in- 
fantile entero-colitis, the summer epidemic of the cities, that this stage, 
which is really spurious hydrocephalus, has been called the stage of effu- 
sion. I shall relate in another place examples which show the anatomical 
characters of this intestinal disease. 

Symptoms. — Spurious hydrocephalus most frequently results from 
protracted diarrhceal complaints. It may, however, result from any dis- 
ease which is attended by great prostration. As it ordinarily occurs, the 
patient has for days or weeks been gradually losing flesh and strength. 
Finally drowsiness supervenes, or before the drowsiness there is some- 
times a period of irritability. 

Marshall Hall describes two stages of spurious hydrocephalus. In the 
first he says : " The infant becomes irritable, restless, and feverish ; the 
face flushed, the surface hot, and the pulse frequent ; there is an undue 
sensitiveness of the nerves of feeling, and the little patient starts on being 
touched, or from any sudden noise ; there are sighing and moaning dur- 
ing sleep, and screaming ; the bowels are flatulent and loose, and the 
evacuations are mucous and disordered." The second stage he describes 
as that of torpor. The first stage often, however, does not present those 
prominent symptoms which have been described by Dr. Hall, and this 
stage may even be absent, or not appreciable, especially in young infants. 



SYMPTO M S . 439 

Whether or not commencing- with the stage of irritability, the disease, 
if not checked, gradually increases. The child soon becomes drowsy. 
He may be aroused for a moment, but, unless constantly disturbed, im- 
mediately relapses into sleep. He is sometimes fretful when aroused, but 
in other instances is quite indifferent, observing without apparent interest 
objects employed for the purpose of amusing him. Often there are indi- 
cations of cerebral pain or distress, as contraction of the eyebrows, etc., 
but many of those affected are too young to make known their sensations. 
Convulsions sometimes occur toward the close of life, but they are not so 
common in this disease as in meningitis. When they do occur, they are 
generally partial and often slight. The pulse is accelerated in most 
patients prior to and in the commencement of spurious hydrocephalus. 
As the disease advances it becomes irregular and intermittent, and toward 
the close of life it is progressively more frequent and feeble. The respi- 
ration at first is not much disturbed, but at length it becomes irregular, 
like the pulse. It is feeble and accompanied by sighs. Occasionally 
there is slight cough. The eyelids are partly open, the pupils no longer 
respond to light, and in advanced cases they have a bleared appearance. 
The diarrhoea, which in most instances precedes and causes this malady, 
continues till the stage of stupor arrives, when the evacuations become 
less frequent or cease altogether. In infants the stools are frequently 
green, in older children brown and sometimes slimy. The febrile heat of 
surface, which preceded the disease and was present in its commence- 
ment, disappears ; the face and hands become cool, the features pallid, 
and the anterior fontanelle, if open, is depressed. Death finally occurs in 
a state of coma, or if the disease be recognized and proper remedial meas- 
ures employed, the result may be favorable, even when the symptoms 
.are such that if meningeal inflammation were the malady we would con- 
sider the case necessarily fatal. 

The following case is an example of spurious meningitis as we often 
meet it in practice : 

Case. — On the 13th day of March, 1859, I w r as asked to see a male 
child twenty -two months old, the records of whose case are as follows : 

" Was well till about three weeks ago, since which time he has had 
diarrhoea, with febrile symptoms ; pulse 162, respiration 52 ; has a slight 
cough, with a few mucous rales ; resonance on percussion of chest good ; 
is somewhat emaciated, and appears languid ; tongue moist and slightly 
furred. Has all the incisor and three anterior molar teeth, and the gum 
is swollen over the remaining anterior molar and two canine teeth." 

" From the 14th to the 18th there was no material alteration in his symp- 
toms, with the exception that the diarrhoea was partially restrained by 
Dover's powder in one and a half grain doses. On these five days the 
stools numbered daily from one to six. The pulse was uniformly fre- 
quent, varying from 124 to 156, and the respiration on two days, when 
its frequency was ascertained, numbered 56 and 46. 

" March 19th, pulse 124 ; has become drowsy since yesterday, and 



440 SPURIOUS HYDROCEPHALUS. 

when aroused is fretful. Omit Dover's powder. Treatment, cold appli- 
cations to the head, mustard pediluvia. 

" Evening, pulse 136 ; eyes constantly closed and head reclining ; 
surface generally warm ; tongue dry and furred ; he vomited at first, but 
has not in three or four days. Apply cantharidal collodion behind each 
ear, and continue the local treatment. 

" 20th, pulse 130 ; is constantly sleeping, and when aroused is very 
fretful and soon relapses into sleep ; no unnatural heat of head, and no 
dejection since yesterday. Treatment, a dose of castor oil, nourishing 
diet. 

" 21st, drowsiness as before ; cheeks sometimes flushed, sometimes 
pallid ; pupils sensitive to light ; margins of eyelids covered with secre- 
tion. The bowels have been opened by the oil." 

On the 22d and 23d there was no material change in the symptoms. 
He was constantly sleeping, except for a moment when shaken. More 
active stimulation was now employed. Brandy was prescribed, to be 
given every two hours ; beef tea and milk porridge frequently. 

On the following day, the 24th, he was more fretful, and less drowsy. 
Brandy and beef tea were continued. 

On the 25th, with the same treatment, there was still further improve- 
ment ; drowsiness nearly gone and less fretfulness than yesterday ; rolls 
the head occasionally and does not appear to see distinctly ; has a slight 
cough ; stools nearly regular ; pulse 100 ; respiration natural ; surface 
warm, and no unnatural heat of head. The same treatment was contin- 
ued, and he rapidly and fully recovered. 

This case is interesting on account of the long duration of marked 
drowsiness, which continued five days, and yet the patient recovered 
entirely in the space of two or three days under the use of brandy and 
beef tea. 

In May, 1860, I was called to treat a very similar case. A child y 
twenty months old, had diarrhoea for two weeks, the stools being of a 
dark-brown color, thin and offensive. He was at first very irritable. 
The pulse was constantly above 130, and the respiration was correspond- 
ingly increased. The stage of drowsiness finally supervened, and for two 
days he was constantly asleep unless aroused by being shaken. During- 
the somnolent stage the pulse numbered 140, respiration 36. The face 
and extremities were cool, and he finally had a slight convulsion. By 
stimulants and nutritious diet he began immediately to improve, and was 
soon out of danger. 

In the following case the result was unfavorable. This case is inter- 
esting on account of the anatomical characters of the disease as disclosed 
by the post-mortem examination. It is an example of that large class of 
cases in which spurious hydrocephalus is associated with congestion of 
the cerebral vessels and serous effusion. It is exceptional, however, as 
regards the long duration of drowsiness. Ordinarily, protracted diar- 
rhoeal maladies which end in passive congestion and effusion terminate- 
fatally in three or four days after the drowsy period arrives. 



DIAGNOSIS— PROGNOSIS. 441 

Case. — " Dec. 13th, 1861, called to-day to a German infant eighteen) 
months old. It has had diarrhoea four weeks without regular and proper 
medical attendance ; stools from the first brown and thin ; during the last 
eight or nine days he has been drowsy ; when aroused, opens his eyes 
and is very fretful, but immediately the upper eyelids gradually droop, 
and, unless disturbed, he remains asleep with his eyes partially open ; 
forehead warm, face cool and pallid, and limbs also rather cool ; pulse 
104, respiration 32 ; has had a slight cough about one week, and slight 
dulness on percussion over the left infra-scapular region ; depression of 
infra-mammary region on inspiration. Treatment : Amnion, carbonat., 
gr. 1 every two hours ; nourishing diet. 

11 Dec. 20th, has continued drowsy since the last record ; pupils mod- 
erately dilated ; a thick secretion between eyelids ; right pupil considera- 
bly larger than the left ; vision apparently lost during the last three days ; 
pulse over 140 ; respiration 44 per minute, accompanied by sighing since 
the 18th ; moans much when awake ; rolls the head frequently ; during 
the last six days the surface back of the ears has been constantly sore by 
vesication ; takes the most nntiitious diet, with brandy. The dejections 
remain thin and brown, and number three or four daily. 

" From this date the diarrhoea continued, except as it was restrained 
by vegetable astringents. The pulse continued frequent, and a slight 
cough remained. There was on the 21st and 22d partial abatement of 
the drowsiness, but on the 23d it was greater than ever. The body was 
somewhat reduced at the commencement of the cerebral symptoms, but it 
was now considerably emaciated. The prostration increased daily, and 
the hands were observed to tremble. The face and hands became more 
cool, while the head was warm. On the 24th partial convulsions oc- 
curred, followed by coma and death. 

" The cerebral veins and sinuses were generally congested, except in 
the anterior portion of the brain, where the appearance was normal. Be- 
tween the brain and its membranous covering, chiefly at the vertex and 
the base, was an effusion of clear serum. The whole amount of this fluid 
was estimated at two ounces. On slicing the brain, numerous ' puncta 
vasculosa ' were seen, both in the gray and white portions. AYith the 
exception of the congestion, the substance of the brain presented its nor- 
mal appearance. No inflammatory lesions were present. We were not 
permitted to examine the condition of the intestines." 

Diagnosis. — The only disease with which spurious hydrocephalus is 
liable to be confounded is meningitis. The points of differential diagno- 
sis are the history of the case, especially the antecedent diarrhoea or other 
exhausting ailment, evidence of prostration when the cerebral malady 
commenced, depression of the anterior fontanelle if it be open, and 
the cool face and extremities. 

Prognosis. — If the pathological state of the brain be simple exhaus- 
tion, the disease can often be arrested by judicious treatment. If an in- 
correct diagnosis be made, and the treatment employed be that appropriate 
for meningitis, which it so closely simulates, death is almost inevitable. 
If transudation of serum have occurred, unless slight, the result is apt to 
be unfavorable, whatever may be the treatment. This disease in child- 



442 ECLAMPSIA. 

hood is more easily managed than in infancy, but is less frequent. The 
prognosis is better in the cool months than during the heat of summer. 
It is more favorable if the child be over than if under the age of one year. 
The occurrence of an irregular and intermittent pulse, of respiration ac- 
companied by sighs, of inequality in the pupils or their sluggish move- 
ments, with increasing stupor, indicates an unfavorable issue. The cure 
of the primary disease, with the pulse and respiration still natural, or ac- 
celerated, without change of rhythm, pupils sensitive to light, drowsiness 
from which the patient is easily aroused to a state of entire conscious- 
ness, render recovery probable, with proper medication and alimentation. 

Treatment. — The indications of treatment are twofold : first, to 
Temove the primary pathological state which is the cause of the spurious 
hydrocephalus ; and, secondly, to cure the latter. The first is impor- 
tant, since the successful treatment of a disease requires the removal of the 
cause. The measures employed for this purpose are pointed out in our 
description of the diarrhceal and other maladies which produce spurious 
hydrocephalus. 

We may here say that as spurious hydrocephalus is due in a very large 
proportion of cases to the exhausting effect of long-continued diarrhoea, 
astringents, especially subnitrate of bismuth, and alkalies are required 
in a majority of cases in the stage of irritability, and sometimes also 
opiates. 

Active sustaining measures are indicated. Exhausted nervous power, 
as well as passive cerebral congestion, requires this. The diet should be 
highly nutritious, comprising such substances as milk and beef juice, 
and should be given frequently. Brandy is required at short intervals. 
Dr. Gooch was in the habit of giving the aromatic spirits of ammonia, 
properly diluted, as a quick and active stimulant. Six or eight drops may 
be given in sweetened water to a child one year old, and repeated every 
hour in cases of urgency. If, by proper treatment of the cause, and by 
the use of stimulants and nutritious food, the patient do not within a 
few hours become less stupid and more conscious, there is that degree 
of nervous exhaustion or of serous transudation from the engorged cere- 
bral veins, which will render death probable. In some cases it is proper 
to produce moderate vesication behind the ears. 



CHAPTEE XI. 

•ECLAMPSIA. 

The term eclampsia is used in a more restricted sense by some writers 
than by others. It is employed in the following pages to designate those 
convulsive seizures, clonic in their character, sometimes general, sometimes 



CAUSES. 443 

partial, which affect the external muscles. Eclampsia is therefore synon- 
ymous with clonic convulsions. It consists in rapid, forcible, and in- 
voluntary muscular contraction, alternating with relaxation. It is distin- 
guished from chorea in the fact that the latter is a more permanent state, 
and is characterized by muscular movements which are partially under the 
control of the will, and are not so violent. 

Eclampsia occurs in a great variety of diseases, some of which are 
located in the cerebro- spinal system, some in other parts of the body, and 
some are constitutional. It may also be produced by temporary derange- 
ments of system, not sufficiently severe to be considered diseases, and by 
powerful mental impressions, those of an emotional nature, affecting the 
delicate and sensitive nervous system of the child. Pathologists recog- 
nize three distinct forms of eclampsia. The term essential or idio- 
pathic is used when the convulsions have no appreciable anatomical char- 
acter, that is, when there is no apparent pathological state in the brain or 
elsewhere, which gives rise to the attack. For example, if a child die 
in convulsions from fright, and all the organs, including the brain, are 
found in their normal state, the eclampsia is called idiopathic or essential. 
If the cause be disease of the brain or spinal cord, it is termed symptom- 
atic. If eclampsia arise from local disease elsewhere than in the cerebro- 
spinal axis, as from pneumonia, the term sympathetic is employed. This 
is in the main a good division, but eclampsia may be at the same 
time sympathetic and symptomatic, as when it occurs in consequence 
of congestion of brain, which is induced by severe and frequent parox- 
ysms of hooping-cough. 

Causes. — Eclampsia occurs at any period of infancy and childhood, 
but it is much more rare after the period of six or seven years than pre- 
viously. Some children are more liable to it than others. It is produced 
in one by an agency which in another has no appreciable effect. There 
are some, generally those of an impressible nervous system, who are seized 
with convulsions whenever there is any slight derangement in the diges- 
tive or other organs. Eclampsia is frequent in certain families. Thus, 
Bouchut mentions a family of ten persons, all of whom had convulsions 
in their infancy. One of them married, and had ten children, all 
which, with one exception, had convulsions. 

The exciting causes of eclampsia are too numerous to be mentioned in 
full. It is a symptom in nearly all cerebral diseases. It is produced in 
the nursling by changes m the milk with which it is nourished. These 
changes are usually due to violent emotions of the mother, as anger, 
fright, and grief, to the use of acescent or indigestible food, or to de- 
rangement, temporary or permanent, in her health. Thus, in a case 
related to me, the catamenia so affected the milk that the infant was 
seized with eclampsia at each monthly period. In childhood the most 
common cause of clonic convulsions is the presence of some irritant in 



444- ECLAMPSIA. 

the primae viae. All kinds of fruit, even the mildest, may produce 
eclampsia, especially when eaten unripe or taken in undue quantity. I 
have known an infant to be seized with convulsions from eating straw- 
berries, which parents usually regard as harmless, and one of the most 
violent and protracted cases of eclampsia which I have witnessed, occurred 
in a child over the age of six years, from swallowing, in considerable quan- 
tity, the parenchymatous portion of an orange. Constipation, worms, 
dysentary, intussusception, and painful dentition are also causes which are 
located in the digestive apparatus. Inflammation in some part of the res- 
piratory apparatus is a not infrequent cause. Thus eclampsia occurs 
occasionally in severe coryza, in consequence, according to some, of the 
proximity of the inflamed surface to the brain, and the consequent afflux 
of blood to this organ. It is a common complication also of pertussis 
and pneumonia. It occurs often at the commencement of two of the 
eruptive fevers, namely, smallpox and scarlet fever, and in the course of 
the latter disease. 

Violent emotions of the child may also cause eclampsia. Bouchut 
relates the case of a girl, five years old, who was corrected before her 
companions, and was so affected by anger that convulsions ensued. Resi- 
dence in close and overheated apartments, or in streets where the air is 
loaded with offensive vapors and is stifling, is a predisposing cause, so 
that there is a larger proportion of deaths from convulsions in the cities 
than in the country. 

In young children, burns, even w 7 hen not very severe, are apt to ter- 
minate suddenly in eclampsia, succeeded by coma and death. Urinary 
calculi, both renal and vesical, frequently produce the same result. 

Such are the more common causes of eclampsia. It is seen that 
they are of two kinds, predisposing and exciting. An excitable or im- 
pressible state of the nervous system constitutes the chief predisposition 
to the disease. Plethora, or its opposite state, anaemia, increases the lia- 
bility to an attack. 

Premonitory Stage. — In the majority of cases there are prodromic 
symptoms, which the experienced and careful physician can detect, so as 
to forewarn friends. The child is perhaps more or less drowsy, and, 
when disturbed, fretful. The eyes often have a wild or unnatural appear- 
ance ; occasionally they are fixed for a moment on an object, and yet ap- 
parently without noticing it. The sleep is disturbed ; in some there is 
unusual heat of head, and, if old enough, complaint of headache. At 
times, especially if the primary disease be febrile or inflammatory, there 
is incoherence of thought or expression, or even actual delirium. In 
some children, when eclampsia is threatening, the thumbs are seen to be 
carried often across the palms. I have observed this especially during the 
convulsive cough of pertussis. A very important prognostic symptom is 
sudden starting, or twitching of the limbs. This shows that the nervous 



SYMPTO M S . 445 

system is profoundly impressed, and but slight additional excitation is 
required to develop eclampsia. This sudden starting not infrequently 
precedes the attack several hours, and gives sufficient forewarning. 

The prodromic symptoms are often disregarded by friends who do not 
understand their significance. Even physicians, in the haste of their vis- 
its, in many instances do not notice them. The symptoms which pre- 
cede symptomatic and sympathetic eclampsia are, moreover, blended with 
those of the primary affection, and hence another reason why they are 
apt to be overlooked. When the convulsions are about to commence, 
the child generally lies quiet ; the eyes are open and fixed. If spoken to 
•or shaken, he takes no notice, and does not speak. The direction of the 
eyes is then changed ; often they are turned up ; sometimes there is stra- 
bismus. The face may be pale or flushed, and sometimes, especially in 
cerebral diseases, the features present patches or streaks of a flushed ap- 
pearance, while around them the natural color is preserved. Immediately 
before the spasmodic movements the child occasionally utters a piercing 
scream, which is probably involuntary, though it seems like a supplication 
for help. The duration of the prodromic stage is very different in differ- 
ent cases. It may last from a few minutes to several hours, or even more 
than a day. 

Symptoms. — Eclampsia is general or partial. If general, the muscles 
of the face, eyes, eyelids, and of all the limbs, are in a state of rapid in- 
voluntary contraction, alternating with relaxation. The features lose their 
natural expression and are distorted ; the mouth is drawn out of shape, 
often to one side, by the violent muscular action ; the teeth are pressed 
together by tonic contraction of the masseters, and may be violently 
struck together, so as to lacerate the tongue, if it protrude, or are ground 
upon each other. Unless the attack be of short duration, frothy saliva, 
perhaps tinged with blood from the injured tongue, collects between the 
lips. The eyelids are usually open, and in severe cases the eyes are 
turned so that the pupils are lost under the upper eyelids, or the muscles 
of the eyes are involved in the spasmodic movements, so that the eyeballs 
are forcibly drawn from side to side. Occasionally strabismus occurs. 
While the features are thus distorted, the head is strongly retracted or is 
turned to one side ; the forearms are alternately pronated and supinated ; 
the thumbs and fingers are convulsively flexed, so that the thumbs lie 
across the palms and are covered by the fingers ; the great toe is 
adducted, the other toes flexed ; and the toes, as well as legs, participate 
more or less in the spasmodic movements. 

In general convulsions, consciousness is usually lost. The head is hot 
previously to and during the attack — at least in the first part of it — and 
the face flushed. In exceptional cases, especially in sympathetic eclamp- 
sia, the head is cool and the face pallid. The pulse is somewhat accel- 
erated, as well as the respiration, and the latter is rendered irregular if the 



446 ECLAMPSIA. 

respiratory muscles, especially those of the larynx, are involved, as they 
generally are. The sphincters are relaxed during the convulsive attack, 
so that in many cases the urine and stools are passed involuntarily. 

Partial eclampsia is more common than the general form : it occurs in 
the muscles of the face, including those of the eye. of the face and of 
one or both upper extremities, or of the face and the extremities on one 
side. The spasmodic movements may be even limited to the muscles of 
the eye, and they often occur only in these muscles and those of the face. 
Rarely, if ever, does eclampsia affect the legs without affecting also the 
muscles of the amis and face. In partial convulsive attacks, sensation 
and consciousness are in some patients not entirely lost, but in others they 
are not manifested if present. 

The duration of an attack of eclampsia varies in different case- from a 
few minutes to several hours, with an average of not more than from live 
to fifteen minutes. The movements do not often continue longer than 
three or four hours in the severest eases. They are sometimes said to 
last a much longer time, even for days, but there are in these cases inter- 
missions. Violent attacks are usually short. 

When the convulsion ends favorably, the spasmodic movements become 
less and less strong, and finally cease. The child then takes a deep in- 
spiration, after whicb it lies quiet, and the respiration remains regular or 
moderately accelerated. Some fully recover in a few minutes if the 
eclampsia have been light and the cause transient, and seem to experience 
no inconvenience except soreness of the muscles and fatigue. Others 
soon recover consciousness, and their temperature, respiration, and circu- 
lation become natural, but they remain dull for a time, their minds are 
bewildered, and they are perhaps unable to speak. In a few hours these 
untoward symptom- pass away. In essential, and in a large proportion 
of cases of sympathetic eclampsia, if properly treated, and if the cause be 
recognized and removed, there is no recurrence of the convulsion ; with 
others it is different. In many cases, especially of symptomatic eclamp- 
sia and of sympathetic, in which the cause is grave and persistent, the 
convulsions return after a variable period of a few minutes or a few 
hours. Six or eight or more convulsions may occur within twenty-four 
hours. Rarely they occur several times daily for several consecutive 
days, but severe convulsions, repeated at short intervals for twenty-four 
or forty-eight hours, usually end in fatal congestion of the brain or serous 
effusion. I once attended an infant about six months old, who had from 
four to twelve convulsions daily for eleven days, caused probably by a 
vesical calculus, as there was dysuna, and, at times, bloody urine. Some days 
after the convulsions were controlled, while we were deferring exploration 
of the bladder, death occurred suddenly, and the autopsy was not permit- 
ted. This case will be detailed elsewhere. Bouchut has witnessed a case 
of hooping-cough in which there were daily convulsions for eighteen days. 



ANATOMICAL CHARACTERS. 447 

In severe eclampsia, the respiration is so embarrassed and circulation so- 
retarded that congestion of various organs results. This passive conges- 
tion in the respiratory organs is indicated by moist rales in the larynx and 
bronchial tubes ; occurring in the brain, it is indicated by profound stu- 
por. It has already been stated that death may occur from the cerebral 
congestioD, which, continuing, is apt to end in effusion of serum or 
extrarasation of blood. In these cases the convulsive movements cease, 
but there is no return of consciousness. The child lies quiet, as if in 
sleep, with pupils not readily acted upon by light, and often somewhat 
dilated ; gradually the limbs grow cool and the pulse feeble, and fatal 
coma supervenes. 

Death does not ordinarily occur from one attack. There are several 
at intervals, during which the stupor is gradually becoming more and 
more profound, till, finally, total loss of consciousness and sensation 
result, terminating in death. Apnoea may occur in the first attack, end- 
ing life abruptly and unexpectedly, but in other instances it does not 
result till after several seizures, when, at length, one more violent than 
the others interrupts the respiratory function and causes death. 

Occasionally, when life is preserved, there is some permanent ill effect 
of eclampsia. Bouchut says : " The origin of certain permanent con- 
tractions which bring on deviation of the head or of other parts, retrac- 
tion of the limb, paralysis, etc., most be referred to the convulsions of 
the muscles. I have seen several children in whom torticollis had no 
other cause. The drooping of the upper eyelid, strabismus, irregularity 
of the mouth, severe contractions of the limbs, often depend on this influ- 
ence. These accidents are consequences of essential as well as of symp- 
tomatic convulsions. 

Anatomical Characters. — The morbid anatomy pertaining to eclamp- 
sia is in most cases twofold : first, the pathological states which precede 
and cause the convulsive movements ; secondly, those which result from 
them. \Ve have seen that in sympathetic eclampsia the diseases which 
sustain a causative relation are very numerous ; some are constitutional, 
others local, and the latter may have their seat in almost any part of the 
economy, distinct from the eerebro-spinal axis. In some cases of sympa- 
thetic eclampsia the immediate cause is too active a circulation, a state of 
hyperemia of the cerebral vessels. 

It has already been stated that this hypera?rma may be diagnosticated 
in voung infants in whom the anterior fontanelle is open. Such infants, 
seized with acute inflammation of the mucous surfaces or of the lungs. 
often present a full and rapid pulse and a convex and forcibly pulsating 
fontanelle before the eclampsia begins. In other cases of sympathetic 
eclampsia the primary disease induces passive congestion of the brain, 
and this in turn gives rise to convulsions. Eclampsia occurring during 
the paroxvsms of hooping-cough affords an example. In the contagious 



448 ECLAMPSIA. 

diseases, as smallpox and scarlet fever, eclampsia is doubtless often pro- 
duced by the direct action of the specific virus on the cerebro-spinal sys- 
tem. Therefore, in a considerable proportion of cases of eclampsia due 
to diseases not located in the cerebro-spinal system — in other words, of 
sympathetic eclampsia — the primary disease induces a pathological state 
of the cerebral vessels, or of the blood which circulates through them, 
which state immediately precedes and accompanies the convulsions. 

In other cases of sympathetic eclampsia the convulsive movements are 
produced by the primary disease acting directly on the nervous system, 
through the medium of the nerves, without causing any appreciable alter- 
ation in the state of the cerebro-spinal axis. Thus Barrier relates three 
fatal cases of convulsions occurring in pneumonia, in none of which was 
there anything abnormal in the condition of the brain or its membranes. 

The pathological state preceding symptomatic eclampsia differs in 
different cases, since convulsions occur in almost every disease of the 
brain and its membranes. The immediate cause of this form of eclamp- 
sia may be active or passive cerebral congestion, with or without effusion ; 
it may be compression of the brain from various causes ; it may be a de- 
ficiency as well as excess of the cerebro-spinal fluid. 

In essential eclampsia the cause sometimes produces congestion of the 
brain prior to the convulsive seizure. In other cases, as when convul- 
sions occur immediately from the effect of anger or fright, there is no ap- 
preciable change in the state of the nervous centres previously to the attack. 

Again, eclampsia, especially when severe and protracted, and when 
occurring in successive attacks, may be the cause of certain lesions. It 
produces congestion of the brain and membranes, and perhaps of the 
spinal cord. Sometimes if the congestion be great, there is also escape of 
serum from the distended capillaries, and the fibrin in the larger vessels, 
as the sinuses may coagulate. 

The congestion resulting from eclampsia may give rise to extravasation 
of blood and the formation of a clot. If this accident occur, there is 
often paralysis affecting more or less of one side, permanent or gradually 
disappearing. 

It may be difficult to decide whether the cerebral congestion precedes 
the eclampsia or is its result ; but in those cases in which it precedes and 
operates as a cause, it is no doubt increased during the convulsive period. 
The spasmodic muscular action, by rendering respiration irregular and 
imperfect, also leads to congestion of the lungs and sometimes of the 
abdominal organs. 

Diagnosis. — The only disease for which there is danger of mistaking 
-eclampsia is epilepsy, but the diagnosis can ordinarily be made by recol- 
lecting the following facts : Eclampsia is most common in infancy. If it 
occur after the age of three years there is some manifest exciting cause, 
which renders the child seriously sick independently of the convulsions, 



DIAGNOSIS. 449 

and prior also to their occurrence. Eclampsia very seldom occurs in one 
who has reached the age of three years, even with a strong predisposing 
cause, unless he have been subject to it as shown by his history during the 
period of infancy. On the other hand, epilepsy rarely occurs before the 
age of three years. The first attacks of it are often very mild, the petit 
mat of writers, but in other cases they are tolerably severe from the first, 
but whether mild or severe, they occur with no previous or coexisting 
sickness, and with little or no warning. 

Having seen a considerable number of epileptic children in the Bureau 
for the Relief of the Out-Door Poor during the last five years, I have been 
surprised to learn how few had eclampsia when infants. It was excep- 
tionally the case that a child having epileptic attacks commencing as or- 
dinarily they did, between the third and tenth years, gave the history of 
infantile eclampsia, and yet the convulsive movements in the two diseases 
seem to be identical. I cannot agree with some that the phenomena in 
eclampsia and epilepsy differ, except as the causes of eclampsia produce 
certain concomitant symptoms, and there is every reason to believe that the 
spasmodic muscular movements proceed from an irritation of the same por- 
tion of the cerebro-spinal axis, to wit, the medulla oblongata. Writers 
like Neimeyer have given reasons for the belief that spasmodic muscular 
movements are produced by functional disturbance of this part of the 
nervous centre. I may state the following, to which I am not aware that 
any one has alluded. If the exposed medulla of an acephalus monster be 
pressed or pinched, convulsions like those of eclampsia and epilepsy re- 
sult. These two diseases, therefore, have a close resemblance anatomi- 
cally and clinically, but by attention to the above facts they can ordinarily 
be distinguished from each other. 

It is often difficult to ascertain the form of eclampsia, whether essen- 
tial, symptomatic, or sympathetic — in other words, to determine the 
cause — till after the convulsions cease. This is especially true when, as 
is frequently the case, the physician is not summoned till the convulsive 
movements begin, and it is necessary that he should act promptly, with 
"but little knowledge of the child's previous history. If there be an obvi- 
ous antecedent disease, as hooping-cough or meningitis, the cause is ap- 
parent ; but if the previous health have been good, or but slightly dis- 
turbed, it may be necessary to make more than one visit or examination 
in order to ascertain the seat and character of the cause. In the majority 
of cases of convulsions occurring suddenly in a state of previous good 
health, the cause is seated in the intestines, but sudden and unexpected 
attacks may be due to the commencement of some inflammatory affec- 
tion, as pneumonia, or of a febrile disease, as smallpox. Unless the 
eclampsia be speedily fatal, the physician, if he examine carefully, will, in 
most cases, soon be able to ascertain the nature of the cause, and diagnos- 
ticate the form of the disease. 
29 



450 ECLAMPSIA. 

Prognosis. — Symptomatic eclampsia is always serious. If it occur in- 
the course of a cerebral disease, it indicates the approach of death, but if 
at the commencement, some may recover. The recurrence of it, what- 
ever the cerebral disease, is an almost certain prognostic of death. 

In idiopathic or essential convulsions the prognosis depends on the 
severity of the attack, and on the age, strength, and previous condition 
of the child. If there be predisposing or co-operating causes, as a ner- 
vous or excitable temperament, or dentition, the prognosis is less favorable 
than when such causes are absent. 

In sympathetic eclampsia the prognosis varies greatly, according to the 
nature of the primary disease, and often according to the stage of that 
disease. If convulsions occur at the commencement of an eruptive fever., 
they generally subside without untoward symptoms, and the fever pur- 
sues a favorable course. Eclampsia, after the appearance of the eruption, 
is premonitory of a fatal result. I have not yet known a patient with 
scarlet fever recover who had convulsions after the rash had covered the 
body, and experienced physicians of this city tell me that their observa- 
tions correspond with mine. Dr. J. F. Meigs, however, relates one 
favorable case. If the cause of the eclampsia be located in or upon the 
mucous surfaces, a majority recover with judicious treatment. In con- 
vulsions consequent on pneumonia or a burn, more die than recover. 

The prognosis in eclampsia is more favorable if the parallelism of the 
eyes be retained, the pupils remain sensitive to light, and consciousness 
soon return. A fatal termination may be predicted, if, after the convul- 
sion, the child remain stupid, without any evidence of returning con- 
sciousness, and the pupils do not respond to light. 

Treatment. — Fortunately, inasmuch as the physician is often required 
to treat eclampsia in ignorance of the cause, the same measures are de- 
manded, to a considerable extent, in all cases, whether the form be essen- 
tial, symptomatic, or sympathetic. As early as possible in the attack 
the feet should be placed in hot water to which mustard is added, or, if 
it can be procured with little delay, a general warm bath may be used in 
place. This has a soothing effect upon the nervous system and promotes 
muscular relaxation, while it also produces derivation of blood from the 
cerebrospinal axis. It is, therefore, useful, especially in those cases in 
which active or passive congestion precedes the eclampsia ; it is also use- 
ful as a preventive of passive congestion and consequent oedema of the 
brain, lungs, and other organs, which are the most serious results of 
eclampsia. It should be continued from six to fifteen or twenty minutes, 
according to the severity and duration of the attack ; at the same 
time cold applications should be made to the head, until its tempera- 
ture, which is usually increased, is reduced. The application of a cloth, 
frequently wrung out of cold water, is the most convenient and ready- 
mode of employing this agent. Cold thus employed acts promptly in con- 



TREATMENT. 451 

trading the vessels of the brain and meninges, and diminishing the cere- 
bral congestion. It tends, therefore, to remove one of the chief dangers. 

Cold applications are also useful for reducing an elevated temperature, 
if it be present. In most cases of eclampsia, if the temperature reach 
103°, the necessity for its reduction is urgent, and the cloths or india-rub- 
ber bag containing ice should be applied not only upon the head, but also 
along the sides of the face, and sometimes over the great vessels of the 
neck. 

As a large proportion of convulsive attacks originate in the condition 
of the intestines, either solely or in part, it is advisable to prescribe an 
aperient unless there be previous diarrhoea. 

The common enema of soap and water will usually produce a free and 
speedy evacuation, and will sometimes disclose the cause of the eclampsia 
in the expulsion of seeds or other indigestible substances or scybala. A 
cathartic is also often required, especially if the enema fail to produce 
sufficient evacuations. In those that are robust, and especially in those 
beyond the age of two or three years, calomel is an excellent purgative, 
is easily given, and is prompt in its action. If the symptoms indicate in- 
testinal inflammation, the milder purgatives, as castor oil, are preferable, 
as they also are in young or feeble children. If the recent ingesta of the 
patient consisted of fruit or of substances of an indigestible character, an 
emetic is appropriate ; a teaspoonful of the syrup of ipecacuanha, re- 
peated if necessary in fifteen or twenty minutes, may be given to a young- 
child, or this syrup with the syrup, scillae compositus to one older and 
more robust. Aside from the ejection of the offending substance which it 
produces, an emetic has some effect in controlling the convulsive move- 
ments. But the cases are rare in which emetics are indicated. 

In addition to the local measures mentioned above, and measures cal- 
culated to relieve the digestive canal of any offending substance, a safe 
medicinal agent which will act promptly in relieving the convulsions is 
urgently demanded, since eclampsia, if severe and protracted, involves great 
danger. Fortunately such agents have been lately introduced into thera- 
peutics, namely, the bromide of potassium or sodium, and hydrate of 
chloral. These agents, while they are effectual, are safe, and, therefore, 
their use has supplanted that of the antispasmodics, assafoetida, valerian, 
lavender, and chloroform, formerly employed ; no one of which, except 
the chloroform, exerts any direct controlling influence over the convul- 
sions, and the chloroform is a dangerous remedy unless used sparingly. 

The bromide of potassium, which I prefer, should be given every ten 
minutes, dissolved in cold water, till the convulsions cease, in doses of 
three grains to a child of one year, and of four or five grains to a child of 
two or three years. When the convulsions cease, the interval between 
the doses should be of course lengthened. In one instance an infant of 
eighteen months was suddenly affected by eclampsia, and the mother in 



452 E C L AMPSIA 

her fright mistaking the directions, gave thirty grains of bromide at one 
dose. Two hours afterward, when I was able to attend, I found that the 
convulsions had ceased at once, and that the patient was playful. Such 
cases show the innocuousness of a large dose of the bromide, and the 
safety in administering the medicinal dose often. 

In severe cases the bromide does not always act with sufficient prompt- 
ness and power. The hydrate of chloral should then be employed, dis- 
solved in two or three drachms of water, and given with a small glass or 
gutta-percha syringe per rectum. If used in sufficient quantity, and re- 
tained by pressure with a napkin, it is quickly absorbed, and will usually, 
in about fifteen or twenty minutes, control the movements. For a child 
of one year I employ about five grains, and for one of four years ten 
grains. With the use of the measures indicated above, eclampsia 
Is, in my practice, much more amenable to treatment than in former 
years. Unless the cause be such that recovery is impossible from the 
very nature of the case, the convulsions will soon cease with these meas- 
ures. It is interesting to observe the effect of the chloral enema. In from 
five to ten minutes the convulsive movements cease in the muscles of the 
face, a moment later in those of the arms, and lastly in those of the 
lower extremities. 

But additional treatment may be required, according to the pathologi- 
cal state which has brought on the eclampsia. If it be an eruptive fever, 
as scarlatina, and the eruption have receded, active revulsive measures, as 
hot mustard baths, are required ; if in dysentery, or other internal inflam- 
mation, the flaxseed and mustard poultice should be applied over the 
parts affected. 

In those dangerous cases in which symptoms of cerebral congestion 
continue after the eclampsia ceases, additional treatment is required. The 
child remains drowsy, does not speak, or apparently suffer in any way, 
and the pupils act less readily than in health. If this condition remain 
after the lapse of a few hours, there is probably serous effusion. All at. 
tacks of eclampsia, unless the mildest, are followed by a period of drow- 
siness, but the persistence of it, with symptoms which indicate hyper- 
semia, with perhaps effusion within the cranium, calls for the employment 
of additional measures. Vesication by cantharidal collodion should then 
be produced behind the ears, mild revulsives be applied to the extremities, 
the head kept cool, the bowels open, and, in certain cases, a diuretic like 
iodide of potassium may be advantageously employed. The utmost care 
should be enjoined in reference to the hygienic management of those 
who are subject to eclampsia. The diet should be nutritious, but bland, 
and all causes of excitement be studiously avoided. 



TETANUS INFANTUM. 453 



CHAPTER XII. 

TETANUS INFANTUM. 

Tetanus or trismus is one of the most interesting diseases of infancy. 
It is first, in point of time, in the long catalogue of fatal maladies. It 
occurs suddenly and unexpectedly in the robust as well as feeble, almost 
certainly destroying life within a few hours under modes of treatment here- 
tofore employed. It is more frequent in some localities and conditions of 
life than in others. In New York it is more common than tetanus at any 
other age, or, indeed, in all other ages, since the mortuary statistics of 
this city exhibit a larger number of deaths from this disease in the first 
year of life than subsequently. Infantile tetanus occurs, with very few 
exceptions, in the new-born. 

Interesting and important as is tetanus infantum, it must be confessed 
that our knowledge of it is much more limited and imperfect than it should 
be, when we consider what great advancement has been made in patho- 
logical inquiries during the present century. Our information in reference 
to its causation, symptoms, and proper treatment is not much in advance 
of that of M. Dazille, or Dr. Joseph Clarke, who lived in the latter part of 
the last century. 

Did we better understand the pathology of diseases in the new-bora, or 
could we more accurately ascertain the condition of organs at this age, 
doubtless we should occasionally consider those phenomena which we now 
designate as a disease per se, under the title tetanus, as symptoms of some 
other affection. But as tetanic rigidity and spasms in the new-born occur 
so abruptly, masking all other symptoms, and ordinarily ending in death, 
without our knowing certainly whether or not there is any antecedent 
disease, it seems entirely proper that we should recognize the state in 
which such muscular rigidity occurs with such a rapid result as an inde- 
pendent affection. This explanation is required from the fact that I have 
added to the accompanying table one case from Billard, which this ob- 
server relates under the head of spinal meningitis. In this case, an infant 
three days old was attacked with convulsions. " His limbs were rigid and 
violently bent ; the muscles of the face were in a continual state of con- 
traction." On the following day " the convulsions continued; 
the body remained rigid, and the vertebral column, which the weight of 
the trunk will cause to bend with the greatest ease in a young infant, re- 
mained straight and immovable whenever the child was raised." At the 
autopsy, in addition to meningeal apoplexy, which is often present in 
those who die of tetanus infantum, a thick pellicular exudation was found 



454 TETANUS INFANTUM. 

upon the spinal arachnoid. There is, therefore, a strict accordance of the 
symptoms and history of this case with those which other observers de- 
scribe as examples of tetanus infantum ; moreover, as a satisfactory reason 
for including this case in our statistics, certain eminent observers, as we 
will see, have reported epidemics of tetanus in which meningitis was the 
principal lesion. 

Fatal Cases. 
Case 1. Male ; taken when three days old ; lived sixty hours. Labatt, 
Edin. Med. and Surg. Jour., April, 1819. 

" 2. Female ; taken when three days old ; lived forty hours. Ibid. 

" 3. Taken when five days old ; lived fifty hours. Ibid. 

" 4. Taken when three days old ; lived one day. Ibid. 

u 5. Male ; taken when two days old ; lived two days. Billard, 
Treatise on Diseases of Children, Stewart's trans., p. 477. 

" 6. Male ; taken when three days old ; lived two days. Romberg. 

" 7. Male ; taken when six days old ; lived ninety -three hours. Dr. 
Imlach, Month. Jour, of Med. Sci., Aug. 1850. 

" 8. Female ; taken at five days ; lived four days. Caleb Wood- 
worth, M.D., Boston Med. and Surg. Jour., Dec. 13th, 1831. 

" 9. Negro ; taken at seven days ; lived twenty-four hours. P. C. 
Gaillard, M.D., South. Jour, of Med. and Phar., Sept. 1846. 

" 10. Male ; taken when seven days old ; lived one day. Augustus 
Eberle, M.D., Missouri Med. and Surg. Jour., 1847. 

" 11. Taken when seven days old. D. B. Nailer, JV. 0. Med. Jour., 
Nov. 1846. 

" 12. Male ; taken when three days old ; lived one day. JV. 0. Med. 
and Surg. Jour., May, 1853. 

li 13. Negro ; taken when three days old ; lived three days. Robert 
H. Chinn, M.D., JV. 0. Med. and Surg. Jour. 

" 14. Taken when two days old ; died in four hours after the doc- 
tor's visit. Ibid. 

" 15. Taken when seven days old ; lived one day. C. H. Cleaveland, 
New Jersey Med. Rep., April, 1852. 

*' 16. Negro ; taken when seven days old ; death finally. Greenville 
Dowell, Amer. Jour, of Med. Sci., Jan. 1863. 

" 17. Taken when twelve days old ; lived one day. Thomas C. Bos- 
well, communicated to Dr. Sims, Amer. Jour of Med. Sci., 
1846. 

" 18. Taken when about five days old ; died at about the age of nine 
days. B. R. Jones. Ibid. 

19. Taken at or soon after birth ; lived two days. Dr. Sims, 
Amer. Jour, of Med. Sci., April, 1846. 

20. Taken at the age of six days ; lived one day. Ibid. 
" 21. Taken when three days old ; lived two days. Ibid. 

" 22. Male ; taken at the age of eight days ; died in three hours. 
Communicated to the writer. 

23. Taken at the age of twelve hours ; lived two days. Commu- 
nicated to the writer. 

24. Female ; taken when seven days old ; lived forty-five hours. 
The writer. 

25. Male ; taken at the age of seven days ; lived about forty-eight 
hours. Ibid. 



a 



i i 



, i 



a 



PElilOD OF COMMENCEMENT. 455 

Case 26. Female ; taken at the age of eight days ; lived three days. Ibid. 

11 27. Female ; taken at the age of five days ; lived three days. Ibid. 

" 28. Female ; taken when four days old ; lived two days. Ibid. 

" 29. Taken when six days old ; died next day. Ibid. 

" 30. Taken when five days old ; lived twenty -four hours. Ibid. 

" 31. Taken when eight days old ; lived two days. Ibid. 

11 32. Male ; taken wheu five days old ; lived one day. Ibid. 

Favorable Cases. 

Case 1. Negro ; female ; taken when three days old ; recovered in a 
few days. Robert S. Baily, Charleston Med. Jour, and Rev., 
Nov. 1848. 

" 2. Negro ; taken at eleven days ; recovered in fifteen days. W. 
B.Lindsay, N. 0. Med.' Jour., Sept. 1846. 

" 3. Negro ; taken when ten days old ; recovered in thirty-one 
days. P. C. Gaillard, Charleston Med. Jour, and Rev., 
Nov. 1853. 

" 4. Male ; taken at the age of eight days ; recovered in twenty- 
eight days. Ibid. 

" 5. Negro ; taken at seven days ; recovered in fifteen days. Au- 
gustus Eberle, Missouri Med. and Surg. Jour., 1847. 

i l 6. Taken when eight days old ; recovered in four weeks. Fur- 
long, Edin. Med. and Surg. Jour., Jan. 1830. 

" 7. Taken at the age of one week ; recovered in two days. Dr. 
Sims, Amer. Jour, of Med. Sci., April, 1846. 

" 8. Female ; taken at the age of three days ; recovered in five weeks. 
The writer. 

Period of Commencement. — Finckh, who saw cases of tetanus of the 
new-born in the Stuttgart Hospital, states [Hecker's Annalen, vol. iii., 
No. 3, p. 304) that it began in one case on the second day after birth, in 
eight on the fifth, and in seven on the seventh. 

Professor Cederschjold, of Stockholm, treated forty-two cases in hos- 
pital practice in 1834, and in these cases it usually commenced between 
the ages of four and six days. Copland says (Medical Dictionary) that it 
generally commences in the first seven or nine days after birth, and rarely 
later than the fourteenth. Romberg states that it commences between 
the fifth and ninth days. In two hundred cases observed by Reicke, in 
Stuttgart, in the course of forty-two years, it was never found to com- 
mence before the fifth, rarely after the ninth, and never after the eleventh 
day. Schneider says that the disease occurs oftenest between the second 
and seventh, and rarely after the ninth day. In six cases reported by Dr. 
C. Levy, of Copenhagen, it began in two on the third day, in two on the 
fifth, and in two on the sixth. Dr. Greenville Dowell (Amer. Jour, of Med. 
Sci., Jan. 1863), who has seen much of tetanus infantum among the 
negroes in Mississippi and Texas, says it is almost sure to come on be- 
tween the fifth and twelfth days after birth. In the forty cases embraced 
in the above table, the disease began as follows : 



456 TETANUS INFANTUM. 

Age. Cases. 

One day or under, 2 

Two days, 1 

Three " 9 

Four " 2 

Five " 6 

Six 3 

Seven " 8 

Eight " 6 

Ten " 1 

Eleven ' 1 

Twelve " 1 

Very rarely, as will be seen hereafter, tetanus begins at or so soon after- 
birth, that it may properly be called congenital. 

Frequency in Certain Localities. — Tetanus infantum occurs proba- 
bly in all countries, but it does not greatly increase the mortality except 
in certain localities. Some of the British and Continental physicians, 
whose observations of disease have been ample, confess that they have 
seen so few cases that they have almost no personal knowledge of 
this malady. On the other hand, there are, or have been, places in every 
zone where it is or has been so prevalent as to sensibly check the increase 
of population. The attention of the profession, more than a half century 
since, was directed to the prevalence of tetanus in the Island of Heimacy, 
off the coast of Iceland. On this island scarcely an infant escaped, while 
on the mainland scarcely one was affected. Heimacy, the product of vol- 
canic action, of small extent and almost destitute of vegetation, supports 
a scanty population. The inhabitants live chiefly on the flesh and eggs of 
the sea-fowl, and are filthy and degraded in their habits. About the year 
1810, the Danish government deputed the landjrtysicus of Iceland to 
visit Heimacy, and ascertain the nature of the disease which was so de- 
structive to the infants. Although this gentleman, from his brief stay, 
saw no case himself, he obtained interesting particulars in reference to 
the disease from the priests and parents. At this time scarcely an infant 
escaped. Again, according to Dr. Schleisner, whose report in reference 
to the same locality was published forty years later, tetanus was still the 
most fatal of all infantile maladies. 

Tetanus infantum is also represented as very fatal in the Island of St. 
Kilda, off the coast of Scotland. In the temperate regions of America 
and Europe cases are not frequent, except occasionally in the poor quar- 
ters of the cities, in foundling hospitals, and rarely in country towns 
where the conditions are favorable for its occurrence. The records of the 
Dublin, Stuttgart, and Stockholm lying-in asylums furnish many cases. 
In the town of Fulda, Germany, in 1802, Dr. Schneider saw six cases 
in fourteen days, while a midwife in the same place stated that she had 
seen more than sixty in nine years. 



causes. 45T 

But the greatest mortality from tetanus infantum is in the warm cli- 
mates, both of the Eastern and Western Hemispheres. In the West In- 
dies, the southern portion of the United States, the equatorial regions of 
South America, and in the islands of Minorca and Bourbon, it has, in 
many localities, been the most frequent and fatal of infantile maladies. 

It is an interesting fact that in the warm regions of the United States 
the victims are chiefly negro infants. L. S. Grier, M.D., of Mississippi, 
says, in the A T . 0. Med. and Surg. Jour., May, 1854 : " The first form, 
of disease which assails the negro among us is trismus. The mortality 
from this disease alone is very great. No statistical record, we suppose, 
has even been attempted, but from our individual experience we are 
almost willing to affirm that it decimates the African race upon our plan- 
tations within the first week of independent existence. We have known 
more than one instance in which, of the births for one year, one-half be- 
came the victims of this disease, and that, too, in spite of the utmost 
watchfulness and care on the part of both planter and physician. Other 
places are more fortunate, but all suffer more or less ; and the planter 
who escapes a year without having to record a case of trismus nascentium 
may congratulate himself on being more favored than his neighbors, and 
prepare himself for his own allotment, which is surely and speedilv to 
arrive." Dr. Wooten (N. 0. Med. and Surg. Jour., May, 1846) says : 
' * It is a disease of fatal frequency on the cotton plantations in this sec- 
tion of Alabama." He has, however, never seen a white child affected 
with it. 

In New Orleans, according to the death statistics in our possession, 
which, however, relate to only one year, tetanus infantum is the most fatal 
of all diseases except phthisis. Mr. Maxwell says, in the Jamaica Pin/sical 
Journal (copied in the London Lancet, April 11th, 1835) : " From obser- 
vations that I have made for a series of years, ... I found that the 
depopulating influence of trismus neonatorum was not less than twenty- 
five per cent. It scarcely has a parallel within the bills of mortality." 
This gentleman's observations relate to the West Indies. Similar state- 
ments are made in reference to this malady as it occurs in Cayenne and 
Demerara in South America. 

While tetanus infantum prevails in regions wide apart, and presenting 
very diverse climatic conditions, there is a similarity as regards the per- 
sonal and domiciliary habits of the people who suffer most from its oc- 
currence. It occurs chiefly among those who are filthy and degraded in 
their habits, who live, either from choice or necessity, in neglect of sani- 
tary requirements. This fact aids us in an understanding of the — 

Causes. — That uncleanliness and impure air are a cause of tetanus is as 
fully demonstrated as most facts in the etiology of diseases. The atten- 
tion of the profession was forcibly directed to this cause by Dr. Joseph 
Clarke in a paper read before the Royal Irish Academy in 1789. This- 



458 TETANUS INFANTUM. 

physician was in charge of the Dublin Lying-in Asylum, and had rightly 
concluded that the mortality among the new-horn infants was due to im- 
perfect ventilation. Through his advice, apertures, twenty-four inches 
by six, were made in the ceiling of each ward ; three holes, an inch in 
diameter, were bored in each window-frame ; the upper part of the doors 
leading into the gallery were also perforated with sixteen one-inch aper- 
tures, and the number of beds was reduced. The results of these simple 
sanitary regulations may be seen from Dr. Clarke's own statement. He 
says : " At the conclusion of the year 1*782, of 17,650 infants born alive 
in the Lying-in Hospital of this city, 2944 had died within the first fort- 
night, that is, nearly every sixth child." The disease in nineteen cases 
out of twenty was tetanus. After the wards were better ventilated, 
namely, from 1782 till the time of the preparation of Dr. Clarke's paper, 
8033 children were born in the hospital, and only 419 in all had died, or 
about one in nineteen. So impressed was Dr. Evory Kennedy, who at a 
later period had charge of the same asylum, with the belief that Dr. 
Clarke had discovered the true cause, and had been able in great measure 
to prevent it, that he writes in his enthusiastic way : " If we except Dr. 
Jenner, I know of no physician who has so far benefited his species, mak- 
ing the actual calculation of human life saved the criterion of his improve- 
ments. ' ' The cases occurring in my own practice have almost all been in 
tenement-houses, where habits of cleanliness are not observed, and I have 
not yet seen, in the practice of others, nor heard of a case which occurred 
in the better class of domiciles. The statement of physicians in the 
Southern States, who speak from extensive observation among the negroes, 
are strongly corroborative of the idea that the disease is in great measure 
due to uncleanliness and impure air. 

Dr. Greenville Dowell, of Texas, states that he has been able to trace 
tetanus infantum to the bedclothes, saturated with excrementitious mat- , 
ters, which are found in the negro cabins. In a paper published in the 
JVashville Journ. of Med. and Surg., June, 1851, by Prof. John M. 
Watson, the frequency of this disease among the negroes is accounted 
for as follows : 

" When called to see their children, we find their clothes wet around 
their hips, and often up to their armpits, with urine. . . . The child 
is thus presented to us, when, on examination, we find the umbilical dress- 
ings not only wet with urine, but soiled, likewise, with fasces, freely giving 
off an offensive urinous and fsecal odor, combined at times with a gangre- 
nous fetor arising from the decomposition, not desiccation, of the cord." 

Another cause is believed to be some irritation in the intestines, as from 
retained meconium. Observers in the Southern States and elsewhere oc- 
casionally mention this as a cause. In one case treated by myself, there 
was obstinate constipation immediately before the attack, and in another 
diarrhoea preceded, and was the only apparent cause. 



causes. 459 

In certain cases the assignable cause is exposure to wet or cold, or to a 
variable temperature, which, it is known, occasionally causes tetanus in 
the adult. Prof. Cederschjold attributed the epidemic which he observed 
in Stockholm to a sudden change of temperature from hot weather in 
May, to frosty in June. In a case related by Dr. P. C. Gaillard, in the 
Southern Jour, of Med. and Pharmacy, Sept. 1846, the disease com- 
menced as follows : The nurse came in with wet apron and clothes, in 
the evening ; a short time after she had taken the child into her lap, it 
sneezed violently two or three times. At 10 p.m. tetanus began. In 
•certain localities on the continent, where there are no parish churches, the 
frequent occurrence of tetanus has been attributed by the physicians to 
the practice of carrying the infants to a distance to be christened, thus 
exposing them to the winds. In this city I have observed tetanus after a 
similar exposure. The influence of the weather in the production of te- 
tanus of the new-born is also shown by facts observed in the Stuttgart 
Hospital. In an aggregate of twenty-five cases treated in that institution, 
all but three occurred in the cold months. In the Island of Cayenne, at 
a hamlet surrounded by mountains and dense forests, tetanus attacked 
only one in every twelve or fifteen of the infants. After a great part of 
the forests had been cut down, so as to allow access to the cold sea winds, 
almost all the new-born infants fell victims to tetanus. (Insel, Cayenne.) 

Hein relates that a citizen of Berlin lost, successively, two children 
with tetanus soon after birth. When the second child fell ill he observed 
that its cradle was exposed to a current of air. At the third accouchement 
the position of the cradle was changed and the infant escaped. Exposure 
to wet and cold has been long recognized as a cause of the disease. Ac- 
cording to Sauvages, " Hie morbus hieme et cum aura lmmida saepius 
advenit quam sicca sestate." [Nosol. Method, vol. i. p. 531.) 

The causes of infantile tetanus, enumerated above, may be proximate 
or remote, may produce the disease by their direct effect on the system 
or indirectly by causing a pathological state which in turn leads to the 
development of the disease. There are other direct causes, namely, or- 
ganic affections. In the bodies of the new-born who die of tetanus, 
lesions are observed which doubtless result from the spasms. Again, others 
are found which, from their nature, could not be a result, and which, 
being observed in different cases, are to be regarded as causes. The 
most frequent of such lesions is inflammation of the umbilicus or um- 
bilical vessels. 

Moschion, who lived in the first century of the Christian era, stated in 
writings still extant that stagnant blood in the umbilical vessels some- 
times produced dangerous disease in the new-born infant, and it is sup- 
posed, though this is doubtful, that he referred to tetanus. In modern 
times the attention of the profession was more particularly directed to 
this cause by a paper published by Dr. Colles, in the first volume of the 



460 TETANUS INFANTUM. 

Dublin Hospital Reports, in 1818. The observations contained in this 
paper were made in the Dublin Lying-in Hospital during the period of 
live years. In each of these years he had witnessed from three to five 
post-mortem examinations in cases of infantile tetanus, and the lesions, 
he states, were- in all much alike, as follows : The floor of the umbilical 
fossa was lined by a membrane apparently formed by suppurative inflam- 
mation, and in the centre of this fossa was a large papilla. This papilla 
consisted of a soft yellow substance, apparently the product of inflamma- 
tion, and in all the cases the umbilical vessels were in contact with this 
substance and were pervious. In a few instances superficial ulcerations 
were found near the mouth of the umbilical vein, and occasionally the 
skin surrounding the umbilicus w T as raised. The peritoneum covering 
the vein was highly vascular, often not to a greater distance than an inch, 
above the umbilicus, but sometimes as far as the fissure of the liver. The 
peritoneum in the course of the umbilical arteries presented the inflam- 
matory appearance in still greater degree, sometimes as far as the sides of 
the bladder. The connective tissue lying along the arteries and urachus 
anteriorly w T as loaded with a yellow watery fluid. The inner surface of 
the umbilical vein w T as not inflamed, but its coats, in general, were thick- 
ened. On slitting open the arteries, a thick yellow fluid resembling 
coagulable lymph, was found within their coats, and in all cases these 
vessels were thickened and hardened as far as the fundus of the bladder. 

Dr. Finckh, who observed twenty-five cases in the Stuttgart Hospital, 
believes that the most frequent cause was suppuration or ulceration of the 
umbilical cord. In ten of the twenty -five cases the navel was dry and 
cicatrized ; in the remainder it was either wet or swollen, with a bluish- 
red inflamed edge at the margin of the navel ; a dirty viscid pus covered 
the umbilical depression. 

Dr. Levy, physician of the Foundling Hospital in Copenhagen, at-, 
tended twenty-two cases in that institution in 1838 and 1839. Of these, 
twenty died, and fifteen were examined carefully after death. In four- 
teen there were decided marks of inflammation in the umbilical arteries, 
especially those portions lying along the urinary bladder ; in several cases 
the peritoneum over the arteries was much injected, and in three adher- 
ent either to the omentum or intestine by coagulable lymph ; the coats of 
the arteries were thickened, their cavities dilated and containing dark- 
reddish brown or greenish puriform matter, always fetid. Sometimes the 
arterial tunica interna was found ulcerated and absent in places, and there 
was spongy thickening of the subjacent connective tissue. In two cases 
the ulcerative process had extended from the tunica interna to the peri- 
toneum, and there was a deposit of thick ichorous matter around the 
ulcer ; in one case both arteries were so softened that their coats were 
scarcely distinguishable, and in another these vessels had become gangre- 
nous. The appearance of the umbilicus was unchanged in four cases ; in 



CAUSES. 461 

ten the fundus was red and filled with puriform fluid, which quickly re- 
appeared when removed, and, in general, shortly before death, the navel 
presented a greenish color. 

According to Romberg, Dr. Scholler made post-mortem examinations 
in eighteen cases of tetanus infantum, and in fifteen found inflammation 
of the umbilical arteries. These vessels were swollen near the bladder, in 
one case to the diameter of four lines, and were found to contain pus. 
The lining membrane was eroded or covered with an albuminous exuda - 
tion. Both arteries were not always equally inflamed, and in three cases 
only one was affected. 

Schneeman found minute points of suppuration in the umbilical vein 
in eight cases (Holscher's Annalen, vol. v. p. 484, 1840), and pus 
throughout the course of this vessel in one. 

The observations mentioned above were made, for the most part, in 
hospitals on the Continent ; but similar observations have been made 
in private practice. M. Borian, of the Isle of Bourbon, says that he 
has found in every case inflammation around the umbilicus (Gazette Medi- 
cale, Paris, July 11, 1841). Dr. John Furlonge (Edin. Med. and Surg. 
Jour., Jan. 1830), who resided at St. John's, Antigua, attributes the 
disease to improper dressing of the umbilicus. The same opinion is ex- 
pressed by Mr. Maxwell, who also saw the disease in the West Indies 
[Jamaica Phys. Jour., copied into the London Lancet, April 11, 1855). 
Dr. Ransom states, in a communication to Prof. John M. Watson (Nash- 
ville Jour, of Med. and Surg., June, 1851), that he has never seen a case 
of tetanus of the new-born in which the umbilicus was healthy. In a case 
related by Robert S. Bailey, in the Charleston Med. Jour, and Rev., 
Nov. 1848, there was a hard scab on one side of the umbilicus, and this 
part was much distended. A discharge followed the removal of the scab 
and the child recovered. In a favorable case, related by W. B. Lindsay, 
in the JV. 0. Med. and Surg. Jour., Sept. 1846, the umbilicus was 
tumid, and not disposed to heal. Dr. H. 0. Wooten (same journal, May, 
1846) attributes the disease to the condition of the umbilicus and um- 
bilical vessels, and states that he has found the umbilicus gangrenous. In 
a case related in the JV. 0. Med. and Surg. Jour., May 1, 1853, the 
umbilical vessels were blocked up by purulent matter. Robert A. Chime, 
M.D., Brazoria, Texas (JV. 0. Med. and Surg. Jour., Sept. 1854), be- 
lieves one cause of the disease to be improper tying and management of 
the umbilical cord, by which a diseased state is produced, which extends 
to the umbilicus, and thence to the viscera. At a meeting of the Ob- 
stetrical Society of Edinburgh, held April 24, 1850, Dr. Imlach related 
a case in which there was a dark and gangrenous appearance on the integu- 
ment around the umbilicus, and the peritoneum underneath was also dark 
but not inflamed ; umbilical vein healthy ; a little fibrin in the left um- 
bilical artery ; right umbilical artery much diseased ; its two inner coats 



TETANUS INFANTUM. 

apparently destroyed, and in their place a yellow pultaceous slough, in 
which pus-globules were discovered with the microscope. 

It is evident that the pathological state of the umbilicus and umbilical 
vessels described above, and which has been noticed by so many observ- 
ers iu different countries, cannot result from the tetanus. It is possible 
that the puriform substance noticed in the umbilical vessels was disinte- 
grated fibrin, which had coagulated at the time of ligation of the cord, and 
the cells seen by Dr. Imlach and others may sometimes have been white 
corpuscles still remaining from the stagnated blood. (Virchoiu's Cellul. 
Pathol.) Still the evidences of inflammation, in at least a part of the 
cases related above, were of a positive character. 

The belief that umbilical lesions occasionally cause tetanus infantum 
comports with the well-known traumatic causation of tetanus in the adult. 
This belief is strengthened by the fact, which will appear farther on in 
our remarks, that tetanus of the new-born, from being frequent in cer- 
tain localities, has become infrequent through greater care in dressing and 
managing the umbilical cord. 

But there are cases of tetanus infantum in which there is no disease in 
or about the umbilicus. Dr. Finckh, of Stuttgart, examined the umbili- 
cal vessels in eleven cases without discovering any pathological change. 
Dr. Samuel B. Labatt, master of the Dublin Lying-in Hospital, published 
in the Edin. Med. and Surg. Jour., April, ]819, a paper entitled " An 
Inquiry into an Alleged Connection between Trismus Nascentium and 
certain Diseased Appearances in the Umbilicus. " This paper w T as de- 
signed as a reply to the essay of Dr. Colles. Dr. Labatt relates several 
cases in which there was no disease of the umbilicus and umbilical vessels, 
and others in which the disease was so slight that it probably produced 
no injurious effect on the health of the child. Dr. James Thompson, 
who spent considerable time in the tropical regions, says {Edin. Med. and 
Surg. Jour., Jan. 1822) : " I have myself examined nearly forty cases 
of infants that have sunk under this complaint. In many I have looked 
at no other part but the navel, and have found it in all states ; sometimes 
perfectly healed, especially if the infants had lived several days ; at 
other times a simple clean wound. When death occurred on the fifth or 
sixth day, the wound was frequently in a raw state. I never yet saw it 
in a sphacelated condition." This writer concludes from his observations- 
that there are cases in which the cause is located elsewhere than in the 
umbilicus or umbilical vessels. In the Dub. Jour, of Med. and Chem. 
Sci., Jan. 1836, Dr. John Breen remarks : " From dissections . 
we have never been able to discover any peculiar morbid appearance which 
would justify us in offering any explanation of the pathology of the dis- 
ease." In my own cases there was no evidence of disease of the umbilicus 
or umbilical vessels so far as could be ascertained bv external examina- 



causes. 463 

tion, and in one (No. 32) a careful post-mortem examination disclosed 
no lesion of these parts. 

The inference from the above observations is that, although umbilical 
disease may be an occasional, probably not infrequent, cause of tetanus 
infantum, cases occur in which such disease is not present, and we must 
look for the cause elsewhere. From the nature of tetanus infantum, the 
cerebro-spinal axis has been from time to time examined in those who have 
died of this malady, and occasionally sufficient cause has been found in 
this part of the system. 

I have alluded in another connection to a case from Billard, in which 
tetanic rigidity occurred in an infant three days old, as the result of 
spinal meningitis. That tonic spasms not infrequently occur in older chil- 
dren in consequence of meningeal inflammation is well known, and in 
some of the reported epidemics of infantile tetanus meningitis was really 
present, and was doubtless the cause of the tonic spasms. Such an epi- 
demic was observed by Professor Cederschjold in Stockholm, in 1834. 
Within a few months he treated forty-two cases, and, in addition to the 
lesions which are known to result from tetanus, there was found in the 
bodies examined a plastic exudation at the base of the brain. Finckh, of 
Stuttgart, made twenty post-mortem examinations of those who had died 
of this disease, and in nine found spinal meningeal inflammation. 

Meningitis in the new-born is, however, rare, and we must regard it as 
an exceptional cause of tetanus. 

In 1846 there appeared from the pen of Dr. Sims, then practising at 
Montgomery, Alabama, a paper designed to show that tetanus of the new- 
born is produced by pressure exerted on the nervous centre, through 
depression of the occipital bone. In 1 848 the same writer published a 
second paper, also, in the Amer. Jour, of Med. Sci., fully enunciating his 
theory as follows : " That trismus neonatorum is a disease of centric 
origin depending on a mechanical pressure exerted on the medulla oblon- 
gata and its nerves ; that this pressure is the result, most generally, of an 
inward displacement of the occipital bone, often very perceptible, but 
sometimes so slight as to be detected with difficulty ; that this displaced 
condition of the occiput is one of the fixed physiological laws of the par- 
turient state ; that when it persists for any length of time after birth it 
becomes a pathological condition, capable of producing all the symptoms 
characterizing trismus neonatorum, which are instantly relieved simply by 
rectifying this abnormal displacement, and thereby removing pressure 
from the base of the brain." In both papers cases are narrated in sup- 
port of this theory, but there are serious objections to this mode of ex- 
plaining the occurrence of the disease. In the first place, if this explana- 
tion were correct, tetanus ought ordinarily to occur sooner, for the occi- 
put is as much depressed previously, and in the majority of cases more 



464: TETANUS INFANTUM. 

depressed than at the period when it does actually commence. Pressure 
on the medulla would certainly be followed by immediate and marked 
symptoms, instead of an immunity for four or five days. 

Again, well-known facts in reference to the causation of tetanus infan- 
tum conflict with Dr. Sims' s theory, as, for example, epidemics of the 
disease, its prevalence in one locality and absence in another, although no 
particular attention be given to the position of the infant, the diminution 
of the number of cases by greater attention to cleanliness, of which there 
is abundant proof. Moreover, there are many reported cases of this dis- 
ease at the commencement of which there was no perceptible displacement 
of the occipital bone. 

The inequality of the cranial bones often observed in tetanus infantum 
should, in my opinion, be explained as follows : When the new-born in- 
fant becomes emaciated the volume of the brain is diminished, like that 
of the trunk or limbs, and the sinking of the occipital bone simply corre- 
sponds w T ith the amount of waste in the cerebral substance. Whatever 
the disease in the young infant, if there be much emaciation, the parietal 
bones will usually be found more prominent than the occipital. Now, in 
fatal tetanus infantum emaciation is very rapid ; those fleshy and plump, 
if the disease do not speedily end, become pinched and wrinkled. Viewed 
in this light, the occipital depression should be regarded as a result, and 
not a cause, of the tetanus. 

Although we do not accept the theory which attributes tetanus infantum 
to occipital depression, there are a few cases on record in which it was ap- 
parently due to injury of the head received at birth. Dr. Sims has related 
one such case, that of a negro infant. The mistress, an observing lady, 
gave to Dr. Sims the following account of it : Its head was " mightily 
mashed. . . . The bones seemed to be loose. I got it to take a lit- 
tle boiled milk on the first day ; but it swallowed very little and very 
badly, for its jaws seemed to be locked. On the next day it took spasms 
and got stiff all over ; its hands were shut up tight, and its arms were 
bent up so (she placed her forearms at right angles). Every time I 
touched it the spasm would get worse all over, screwing up its face till it 
was the ugliest thing in the world ; and when the spasms wore off it 
looked as well as any other new-born baby. But then the stiffness never 
left it, and the spasms kept coming and going till it died. ' ' It lived two 
days. 

It is evident, from the description given by the mistress, that this was 

a case of tetanus commencing at or so soon after birth that it seemed 

almost congenital. The apparent cause was injury of the head, occurring 

" in consequence of protracted birth, the infant being resuscitated with 

difficulty after several minutes. 

Dr. W. C. Sutton published a similar case in the Nashville Jour, of 
Med. and Surg., April, 1853. The infant at birth was apparently dead, 



CAUSES. 465 

but was resuscitated so as to live eighteen hours in a state of tetanic rigid- 
ity. In cases in which tetanus begins at birth, doubtless, the cerebro- 
spinal axis is in some way affected ; but in the absence of post-mortem 
examinations, the exact nature of the lesion is uncertain. 

It is evident, therefore, that in this disease, as in eclampsia, the cause 
in different cases may be entirely distinct. Dr. James Johnson, many 
years ago, expressed his belief in the multiplicity of causes, and he had 
been a careful and intelligent observer in the West Indies. 

The causes may be arranged in two groups, one external, the other in- 
ternal. In the first group should be placed imperfect ventilation, personal 
and domiciliary uncleanliness, and atmospheric vicissitudes ; in the sec- 
ond group, so far as ascertained, inflammation of the umbilicus and umbili- 
cal vessels, meningitis, and, rarely, injury of the cerebro-spinal axis dur- 
ing birth. 

The lesions resulting from tetanus infantum pertain chiefly to the circu- 
latory system. In the cases examined by Professor Cederschjold, of Stock- 
holm, already alluded to, the meningeal and cerebral vessels, and those of 
the spinal cord, the cavities of the heart, and the large vessels connected 
with the heart, were distended with blood. 

Finckh made post-mortem inspection of twenty cases in the Stuttgart 
Hospital, the bodies at death having been placed on their faces, in order 
to prevent any deceptive appearance from the gravitation of blood. In 
four there was no appreciable alteration in the spinal cord or its mem- 
branes. In the remaining sixteen there was effusion of blood, in consid- 
erable quantity, the whole length of the spinal cord, between the bony 
walls and the dura mater. It should be stated, however, that there was 
spinal meningeal inflammation in nine of the sixteen, though the extrava- 
sation did not, probably, result from the inflammation, but from the 
tetanus. The blood in Finckh's cases was very dark, sometimes fluid, at 
other times coagulated. In one case there was no change in the ap- 
pearance of the brain or its membranes. In the remaining nineteen, more 
or less extravasated blood was found on the surface of the brain, or in its 
interior. The substance of the brain was healthy, as also its membranes, 
except the congestion. The only abnormal appearance observed in the 
thoracic and abdominal viscera was strong contraction of some portion of 
the intestinal tube in five cases. Dr. West says : " The most frequent 
post-mortem appearances in these cases"' — referring to tetanus infantum — 
" and that which I found in the bodies of all the four children whom I 
observed, consists of effusion of blood, either fluid or coagulated, into the 
cellular tissue surrounding the theca of the cord. Conjoined with this 
there is generally a congested state of the vessels of the spinal arachnoid, 
and sometimes an effusion of blood or serum into its cavity. The signs 
of congestion about the head are less constant, though much oftener 
present than absent, and sometimes existing in an extreme degree ; while 
30 



46f) TETANUS INFANTUM. 

in one instance I found not merely a highly congested state of the cere- 
bral vessels, but also an effusion of blood, in considerable quantity, between 
the skull and dura mater, and also a slighter effusion into the arachnoid 
cavity. ' ' Dr. Weber, of Kiel, also placed infants who had died of tetanus 
on their faces, and, without exception, found injection of the capillaries 
of the cord and spinal meninges, and extravasation of blood. M. Matus- 
zynski, according to Bouchut, " has observed effusions of blood of vari- 
able quantity, in the cerebral pia mater, in the ventricles, and in the choroid 
plexuses, with considerable injection of the membranes of the brain. He 
has also seen serous infiltration beneath the arachnoid, and serous effusion 
into the ventricles, accompanied by a diminution of the consistence of 
the cerebral substance." In two cases examined by myself there was 
intense injection of the cerebral meninges and of the meninges of the 
upper part of the spine, but no extravasation was noticed. The spinal 
canal was not opened. In a third case, in which the spinal canal was 
opened, there was extravasation in addition to the congestion ; this was 
especially observed along the spinal theca. 

Dr. H. O. Wooten (JV. 0. Med. and Surg. Jour., May, 1846) states 
that he has made several post-mortem examinations, and has found the 
pathological appearances as uniform as in any other disease, as follows : 
" Engorgement of the substance of the brain, and of the meninges lining" 
the base of the brain, the medulla oblongata, and spinal marrow ; liver 
congested." 

In a case related by Dr. Imlach before the Edin. Obst. Soc, April 
24th, 1850, the upper part of the lungs was healthy, the posterior por- 
tion congested, and containing many dark points ; heart and liver 
healthy ; small intestines of a light-brown color ; stomach and large in- 
testines pallid ; there had been umbilical haemorrhage. 

Romberg states that he found in a child, whose death occurred from thi& 
disease, such intense congestion of the veins and sinuses of the brain,, 
that a slight touch, and the removal of the cranial bones, produced ex- 
travasation of the partly coagulated and partly fluid blood. Dr. Scholler^ 
on the other hand, found actual extravasation of blood in the spinal canal 
in only one case in eighteen. 

It is seen from the above observations, that tetanus of the infant is 
ordinarily accompanied by great passive congestion, which is especially 
marked in the cerebro-spinal axis, and that frequently extravasations 
occur from the distended capillaries. The embarrassment of respiration 
and the retarded circulation of blood consequent on the tetanic rigidity, 
afford sufficient explanation of this state of the vessels. 

Symptoms. — In many cases premonitory symptoms are absent, or are 
so slight as to escape notice. Sometimes there is a degree of fretfulness 
previously, but no more than is often observed in those who continue in 
good health. The first symptom which alarms the parents, and shows 



SYMPTOMS. 467 

the grave nature of the commencing disease, is inability to nurse, or evi- 
dent pain and hesitation in nursing. Commencing with rigidity of the 
masseters, the disease gradually extends to the other voluntary muscles, 
and in the course of a few hours the muscles of the limbs, as well as of 
the trunk, are involved. Persistent muscular contraction, which is the 
pathognomonic feature of infantile tetanus, is developed not fully in the 
beginning, but by degrees in each affected muscle, so that it is not till 
after the lapse of several hours, perhaps even a day, that the greatest 
amount of rigidity is attained. Therefore, in the commencement of the 
disease, the limbs can be bent, and the jaws pressed open, more readily 
than at a subsequent stage, though with manifest pain to the infant. 

During the period of maximum rigidity, the jaws are fixed almost im- 
movably, often with a little interspace between them, against which the 
tongue presses, and in which frothy saliva collects. The head is thrown 
backward and held in a fixed position by the stiffness of the cervical mus- 
cles. The forearms are flexed ; the thumbs are thrown across the palms 
of the hands, and are firmly clenched by the fingers ; the thighs are 
drawn toward the trunk ; the great toes are adducted, and the other toes 
flexed. Occasionally opisthotonos results from the extreme contraction 
of the dorsal and posterior cervical muscles. The infant can sometimes 
be raised without any yielding of the muscles, by one hand under the 
occiput and the other under the heels. 

The rigidity is liable to variation in its intensity, even after the full de- 
velopment of the disease. If the infant be quiet, especially if asleep, the 
muscles are partially relaxed to such an extent sometimes, in the first 
stages of the complaint, that the features have a placid and natural ex- 
pression, though only for a short time. There are frequent exacerbations 
in the muscular contraction, sometimes occurring without any apparent 
cause, and sometimes produced by anything which excites or disturbs the 
child. Attempts to open the lips or jaws, or eyelids, or to bend the 
limbs, blowing on the face, or even the crawling of a fly upon it, occa- 
sions the paroxysm. 

During the paroxysm the eyelids are forcibly compressed, as well as 
the lips, which are either drawn in or are pouting ; the forehead and 
cheeks are thrown into wrinkles, and the physiognomy is indicative of 
great suffering. The unnatural positions of the trunk and limbs, which 
result from the muscular contraction, are increased for the moment ; the 
head is more forcibly thrown back, and the limbs more strongly flexed. 
The muscular movements which occur during the paroxysms are some- 
times described as clonic spasms. There is indeed occasionally some 
quivering of the limbs, and yet, as I have on different occasions noticed, 
so far from the muscular action being a clonic spasm, it is clearly tonic, 
and is intensified during the paroxysm. In fatal cases the paroxysms 
occur more and more frequently until the period of collapse. 



468 TETANUS INFANTUM. 

The crying of the child affected b)' tetanus is never loud, however great 
the suffering. It is variously described by writers as " whimpering" or 
"whining." It is of this suppressed character in consequence of the 
rigid state of the respiratory muscles and their imperfect movement. 

During the exacerbation respiration is suspended, or so imperfect, ana 
the circulation so retarded, that the surface becomes of a deep red, 
almost livid, color. Sometimes epistaxis occurs, affording partial relief 
to the congestion, and sometimes, though less frequently, the blood 
forces itself from the congested liver along the umbilical vein, and 
escapes from the umbilicus. The intense passive congestion consequent 
on the tetanic spasm is general throughout the system, but extravasation 
of blood appears to be more common around the brain and spinal cord 
than elsewhere. 

The frequency of the pulse and respiration varies in different cases, 
and at different stages of the same case. They are often somewhat accel- 
erated, but at other times are natural, or are even slower than in health. 

While the appetite of the infant, to appearance, is not diminished, the 
pain which it experiences in nursing is such that alimentation is necessa- 
rily deficient. It can be fed with a spoon for a time after it ceases to 
take food in the natural way, but artificial feeding soon fails. The milk 
placed in its mouth is in great part pressed back through the violence of 
the spasm which is induced by the attempt to feed it. 

In consequence of imperfect nutrition, the infant rapidly wastes away. 
There is no other disease except the diarrhoeal affections in which emacia- 
tion is so rapid. In a case related by Dr. W. B. Lindsay in the JV. 0. 
Med. Jour., Sept., 1846, the record states that " the infant was fat 
three days before, but was now emaciated. ' ' Eomberg, who saw tetanus 
infantum in European hospitals, and Dr. Robert H. Chinn, of Texas (N. 
0. Med. and Surg. Jour., Sept., 1854), both speak of the rapid emacia- 
tion. The trunk and extremities lose their fulness, and the features be- 
come pinched. Several observers have noticed the appearance of miliaria 
in this reduced state of system, especially around the shoulders, and 
sometimes a decidedly icteric hue appears on the skin. 

The condition of the intestines is not uniform. They may be relaxed, 
particularly if the disease be due to some irritation in them ; in other 
cases the stools are natural or constipated. 

It is often difficult to ascertain the state of the eyes, since attempts to 
open the eyelids bring on spasms and cause firm compression of the lids 
against each other. According to Sir Henry Holland, one of the first 
symptoms which occurred in cases on the island of Heimacy was strabis- 
mus, with rolling of the eyes. But this statement must be received with 
caution, since these cases were not seen by any physician, and the infor- 
mation was obtained from the parents and priests. If true, the proxi- 
mate cause of the disease in Heimacv would seem to be located in the 



DURATION IN FATAL CASES. 469 

cerebro-spinal axis. Contraction of the pupils commonly occurs in the 
stage of collapse. 

Mode of Death. — Death in infantile tetanus may occur from apnoea 
in the paroxysms, from extreme congestion of the cerebral vessels, or 
apoplexy ; and, lastly, it may occur from exhaustion. The last mode is, 
probably, the most frequent. 

Prognosis. — All writers till recently agree that tetanus of the infant 
rarely terminates favorably. Cull en attributes the ignorance of phy- 
sicians in regard to this disease to the fact that it is so little amenable to 
treatment that they are not usually summoned to attend those affected 
with it. In the Island of Heimacy, of one hundred and eighty-five cases, 
occurring during a series of years about the commencement of the present 
century, not one survived ; and in the same locality, at Westmannoe, 
a small islet, sixty-four per cent of all the infants born died of trismus. 
(Report of Dr. Schleisner.) Similar statements in regard to the mortal- 
ity of tetanus infantum are given b} T physicians in the Southern States. 
Dr. H. 0. Wooten, of Alabama, says (JV. 0. Med. Journ., May, 1846) 
that he has " never seen a decided case of tetanus nascentium that did 
not prove fatal, . . . and that it is very generally deemed useless to 
call in medical aid after the initiatory symptoms are well declared. 1 ' Mr. 
Maxwell, speaking in reference to the West Indies, says (Jamaica Phys. 
Journ., copied into the London Lancet, April 11, 1835) : " From ob- 
servations which I have made for a series of years, ... I found 
that the depopulating influence of trismus nascentium was not less than 
twenty-five per cent. It scarcely has a parallel within the bills of mortal- 
ity." Dr. D. B. Nailer (N. 0. Med. Journ., Nov., 1846) says: 
" About two thirds of the deaths among the negro children are from this 
disease, and so uniformly fatal is it, that a physician is never sent for." 

Yet death does not always result. Eight of the forty cases in my col- 
lection recovered ; but a correct opinion cannot be formed from this of 
the actual ratio of favorable to unfavorable cases, since favorable cases are 
much more likely to be published. In the history of these eight cases, 
two interesting facts are noticed, which, when present, may serve as a 
ground for hope of a successful termination. These were, the age at 
which the disease began, and fluctuation in the symptoms. With two 
exceptions, the infants who recovered were about a week old when the 
initiatory symptoms appeared, and there were fluctuations in the gravity 
of the symptoms ; whereas, fatal cases ordinarily grow progressively 
worse. Yet, in favorable cases, the symptoms are never so severe as they 
become in a few hours in those who succumb. 

Duration in Fatal Cases. — Of eighteen cases observed by Finckh in 
the Stuttgart Hospital, fifteen died in two days, two in five days, and one 
in seven days. During the epidemic in the Stockholm hospitals, in 1834, 
where forty -two cases were treated, the disease seldom lasted more than 



470 TETANUS INFANTUM. 

two days. Romberg says : " It generally lasts from two to four days, 
but its duration is at times limited at from eight to twenty-four hours, 
and occasionally, though rarely, it extends from five to nine days." 

In thirty-one fatal cases in my collection, in which the duration is men- 
tioned : 

One lived .3 hours. 

Eleven others lived . . . . . 1 day or less. 

Twelve lived . . . . . . .2 days. 

Four lived . . . . . . . 3 days. 

Three lived 4 days. 

Both Underwood, who published a little treatise on diseases of children 
in 1789, and Dr. Elsasser, at a more recent date, record fatal cases which 
were unusually protracted. The one described by Underwood was 
treated in the British Lying-in Hospital, and, although all the others 
treated in this institution died by the third day, this lived six weeks ; but 
it is suggested by the author that death was due in part to some other 
affection. The child treated by Elsasser lived thirty-one days. 

Duration in Favorable Cases. — In the eight favorable cases in my 
collection, the duration of the disease, reckoned from the time when the 
infant ceased nursing till it began again, was as follows : In one case, two 
days ; in one, a few days ; in one, fourteen days ; in two, fifteen days ; 
in one, twenty-eight days ; in one, twenty-one days ; and in the remain- 
ing case, about five weeks. 

Diagnosis. — To one who has seen this disease in the new-born, or is 
familiar with its symptoms, diagnosis is easy. The symptoms which pos- 
sess diagnostic value are more manifest and reliable than in most other 
infantile maladies. Permanent rigidity of the voluntary muscles, with 
temporary exacerbations, such as have been described above, which are 
induced by any cause which disturbs the infant — as attempts to open the 
mouth or eyelids — is pathognomonic. 

Preventive Treatment. — While tetanus infantum, if fully developed, 
is ordinarily fatal, in spite of any remedial measures heretofore used, 
there is no doubt of the efficacy and value of preventive measures, when 
properly employed. This was shown by the great reduction in mortality 
in the Dublin Lying-in Hospital through the thorough ventilation intro- 
duced by Dr. Clarke. Dr. Meriwether, of Montgomery, Ala., says 
(Amer. Joum. of Med. Sci., April, 1854) : " When the disease appears 
endemically on a plantation, it may be arrested by having the negro 
houses whitewashed with lime, inside and out ; by raising the floors 
above the ground ; by removing all filth from under and about the 
houses ; by particular attention to cleanliness in the bedding and clothes 
of the mother ; and in the dressing of the child, so as to prevent any of 
the matter from the umbilicus lying long in contact with the skin." 
Many physicians, especially in the Southern States, speak confidently of 



TREATMENT. 471 

care in dressing the cord and attention to the umbilicus, as a means of 
prevention. In the JV. 0. Med. and Surg. Journ., July, 1853, Dr. 
Grafton says that he has " never known the disease to occur in any child 
whose navel had the turpentine dressing." He uses turpentine as fol- 
lows : " At the first time, a few drops of the undiluted turpentine are 
applied immediately to the umbilicus around the cord, and it is anointed 
at every succeeding dressing, the turpentine being diluted one half or two 
thirds with olive oil, lard, or fresh butter." This use of turpentine has 
also been recommended by other practitioners in the warm regions. 

Dr. John Furlonge, of St. John's, Antigua, believes (Edin. Med. and 
Surg. Jour., Jan., 1830) that no case would occur with the following 
treatment : " The cord, when divided, should be wrapped in clean linen. 
Every night, for two weeks, one or two drops of tinct. opii and spts. vini, 
equal parts, should be given, and castor oil, with a little magnesia, every 
morning. The child must be washed in tepid water every morning, and 
the funis dressed. ' ' If this treatment be attended by the success Avhich is 
claimed for it by Dr. Furlonge, so great care in dressing the cord is cer- 
tainly well repaid in localities, as at Antigua, where a large proportion of 
the infants die of tetanus. 

Some experienced observers go so far as to assert that it is possible to 
ward off tetanus infantum after the occurrence of premonitory symptoms. 
Dr. Dowell says (Amer. Jour, of the Med. Sci., January, 1863) : 
" Some, with slight twitch ings of the muscles, have recovered without 
any trouble by being put into a mustard-bath, washed clean, and put in a 
clean and well-ventilated cabin." 

Treatment. — In considering the effect of medicinal agents which have 
been employed in the treatment of infantile tetanus, the great difficulty 
which the child experiences in swallowing should be borne in mind. With- 
out care, a considerable part of the dose is lost by the spasm of the mus- 
cles of deglutition, which ordinarily occurs when the spoon is placed in 
the mouth, so that, unless special attention be given to this matter, it is 
uncertain whether the prescribed dose is fully administered. 

The treatment employed by different physicians has been very diverse. 
Antiphlogistic remedies were prescribed by Finckh, but every case so 
treated was fatal. He states that whenever blood was abstracted, even in 
small quantities, the symptoms were aggravated. The same result has fol- 
lowed depletory measures in the practice of other physicians. 

The internal remedies which have been most frequently prescribed are 
opiates and antispasmodics. Furlonge, in a favorable case, gave lauda- 
num, in doses of one drop every three hours, alternately with two grains 
of Dover's powder. Woodworth also gave one-drop doses of laudanum ; 
Eberle, one sixth of a drop hourly. The opiate has generally been given 
in combination with an antispasmodic. The Dover's powder, given 
every three hours by Furlonge, was combined with five grains of sulphate 



472 TETANUS INFANTUM. 

of zinc. The hourly doses of laudanum, by Eberle. were combined with 
six drops of tincture of assafoetida. 

When anaesthetics began to be employed in the treatment of diseases it 
was believed that they would be especially useful in cases of tetanus. 
Accordingly chloroform has been used in tetanus in the infant, with the 
effect of controlling the spasm during the time of its use, but without 
curing the disease. In Case 7 in our first table it was employed several 
times, but apparently without delaying the fatal result. The editor of 
the New Orleans Medical and Surgical Journal states, in the May issue 
of that periodical for 1853, that he has used chloroform in tetanus infan- 
tum, with the effect, he believes, of prolonging life. Anaesthetics cer- 
tainly relieve the suffering of the infant, and on this account, even if 
they do not prolong life, their judicious employment seems proper. 

The remedy which, in my opinion, is far preferable to all others, is 
hydrate of chloral. Since the introduction of this agent into therapeu- 
tics, it has been employed by several physicians in the treatment of this 
disease with so good a result that it will probably supersede all other 
medicines for this purpose. Dr. Widerhofer, of Vienna, states that he 
has saved six out of ten or twelve by the use of chloral [London Lancet, 
March 18, 1871). He prescribes it in doses of one to two grains by the 
mouth, or, if there be great difficulty in swallowing, two or four grains by 
the rectum. Dr. F. Auchenthales relates a case (Jahrb. f. Kinderheil., 
N. S., IV.) in which he gave even six-grain doses, and in nine days the 
disease had entirely disappeared. I have recently employed hydrate of 
chloral in a case of tetanus, giving it in half-grain doses, every two 
hours, except when there was profound sleep. The disease was fully de- 
veloped, and the symptoms severe when I was called. I did not believe 
that the infant with the old remedies would live more than two days, but 
by the chloral life was prolonged nearly one week. Moreover, by the use 
of chloral the suffering of the infant is greatly diminished. The frequent 
inhalation of sulphuric ether also aids materially in controlling the spasms. 
The administration of alcoholic stimulants is required at short intervals 
on account of the rapid emaciation and great prostration. 

Local treatment directed to the umbilicus in those cases in which there 
is evidence of inflammation of the umbilicus or umbilical vessels should 
not be neglected. The application of an emollient poultice to the umbili- 
cus has been followed by apparent improvement, if we may believe 
the statement of some physicians who have made use of this treat- 
ment. Dr. Merriwether, of Alabama, says, if there be no improve- 
ment from the medicine which he orders, he applies a blister, larger than 
a dollar, to the umbilicus, and with this treatment the child generally im- 
proves ; a remarkable statement, since so few improve at all. 

A warm foot-bath, repeated at intervals of a few hours, and stimulat- 
ing embrocations along the spine, are proper adjuvants to the treatment. 



INTERNAL CONVULSIONS. 47*£ 



CHAPTER XIII. 

INTERNAL CONVULSIONS. 
(Spasm of the Glottis, Laryngismus Stridulus.) 

Young children are liable to temporary suspension of respiration, in- 
duced by violent emotions, especially by anger. In the midst of their 
excitement, while they are crying or screaming, their breath is suddenly 
held, as if from tonic spasm of the respiratory. muscles. In a few sec- 
onds respiration returns and is natural. There is no stridulous inspiration 
or other unusual sound, and there is no apparent ill effect, unless occa- 
sionally a degree of languor. External convulsions, which seem to be 
threatening, seldom occur, and when they do, are ordinarily mild. Some 
writers consider dentition the predisposing cause of this arrest of respira- 
tion, by inducing a sensitive state of the nervous system. Such an effect 
of dentition is possible, but certainly many infants are affected in this 
manner before the age of dentition. 

A much more serious state, and one which is recognized as a true dis- 
ease, is that variously designated by writers as internal convulsions, spasm 
of the glottis, child-crowing, laryngismus stridulus, etc. Manifest diffi- 
culties attend the investigation of the pathological state in this disease. 
There can be little doubt that it is not precisely the same in all cases. 
That there is, during the paroxysms, tonic or clonic spasm of more or 
fewer of the respiratory muscles is inferred not only from the symptoms 
pertaining to the respiratory apparatus, but from the fact that in severe 
cases there are often spasms of the external muscles, as those of the limbs 
and face. Usually, also, the movements of the eyeballs indicate spas- 
modic contractions of the motor muscles of the eyes. The fact of spas- 
modic muscular action in parts that arc visible justifies the belief that it 
occurs in other parts which are concealed from view, especially as the 
characteristic symptoms cannot be readily explained except on this sup- 
position. Trousseau says : " Internal convulsions consist, then, princi- 
pally in a spasm of the diaphragm and of the respiratory muscles of the 
abdomen and chest ; but it occurs, also, that the muscles pertaining to 
the larynx are affected with spasm at the same time with these." Rilliet 
and Barthez conclude from the symptoms that the ' ' heart is not always 
a stranger to this internal convulsion, which, perhaps, prolongs itself even 
to the intestines." The muscles of the pharynx appear to be involved, 
in some cases, as well as those of respiration, rendering deglutition diffi- 
cult. In one form of internal convulsions, namely, that which is princi- 



474 INTERNAL CONVULSIONS. 

pally referred to by writers, there is not complete arrest of respiration, 
but the inspirations, during the paroxysms, are difficult and are attended 
by a stridulous noise. Again the respiration may cease entirely, but when 
it commences it is stridulous, and difficult for a few inspirations. In still 
another form of the disease respiration ceases, but there is no symptom 
or sign indicative of glottic spasm or of an obstacle to the ingress of air ; 
the inspirations which succeed the paroxysm are easy and noiseless. It 
has been suggested that, in these cases, there is paralysis rather than 
spasmodic contraction of the respiratory muscles, but the symptoms may 
be explained in accordance with the commonly accepted opinion, namely, 
that there is spasm of the diaphragm and, perhaps, of certain muscles of 
the chest and abdomen, while the laryngeal muscles are not affected. M. 
Herard, indeed, who has written one of the best monographs on internal 
convulsions, describes three forms of the disease, according to the sup- 
posed location of the spasm, namely, laryngeal, diaphragmatic, and 
another, which consists of a blending of the two. 

Internal convulsions are not frequent in this country ; they are rare 
in France, more frequent in Germany, and quite common in England. 
They occur, with few exceptions, before the age of two years. Dr. 
West observed thirty-one cases under the age of two years, and only 
six above that age. 

Causes. — The causes of internal convulsions are not fully ascertained. 
Most observers have remarked the relative frequency of the disease dur- 
ing the period of dentition, and it is probable that dental evolution does 
operate as a cause, by rendering the nervous system more impressible. 

Spasm of the glottis has been attributed to enlargement of the thymus 
gland, and also to enlargement of the cervical and bronchial glands. It is 
presumed that this effect is due to the pressure of these glands on the par 
vagum, or the recurrent laryngeal nerve. It is certain, however, that 
there is no such enlargement of the thymus gland wmich could possibly 
produce glottic spasm, or any other form of internal convulsion at the age 
at which these convulsions commonly occur. This gland is largest in the 
new-born, and having no function after birth, it gradually becomes atro- 
phied. If an enlarged thymus could produce glottic spasm, it would certain- 
ly occur most frequently in the new-born. Abnormal development of the 
thymus gland was the only assignable cause of atelectasis in two infants who 
died soon after birth, but I have never seen a case in which a convulsive 
attack was referable to this cause. M. Herard examined the thymus 
gland in six children who died of internal convulsions, and in sixty who 
died of other affections, and was not able to discover in its condition any 
causative relation to this disease. Indeed, cases have been reported in 
which the thymus had undergone more than its usual atrophy at the time 
when the convulsions occurred (Hasse). Enlargements of the lymphatic 
glands in the vicinity of the pneumogastric or recurrent laryngeal nerve 



causes. 475 

may possibly give rise to glottic spasm, but this is doubtless an infre- 
quent cause, if it be a cause at all, since these glands are often greatly 
enlarged in strumous and tubercular diseases without such a result. Ac- 
cording to Dr. Jacobi (N. Y. Jour, of Med., Jan. 1860) : " In some 
cases, described by Dr. Friedleben, a congenital hypertrophy of the 
thyroid gland has probably been the cause of laryngismus. The pa- 
tients were new-born infants of normal development, and born by nor- 
mal labors. There were no constitutional causes of the disease, but a re- 
markable vascular swelling of the thyroid gland. Whenever the swelling- 
increased, the veins of the face and head increased in size also, the face 
grew livid, and the extremities and spinal column exhibited slight tonic 
convulsions. The recurrent nerves were entirely surrounded by the glan- 
dular tissue, their neurilemma looked unusually red, and their functions 
were probably injured during the occasional swelling taking place during 
lifetime. ' ' 

The cause is occasionally located in the cerebro-spinal axis. Thus Dr. 
Coley relates a case in which an exostosis arising from the internal surface 
of the occipital bone pressed upon the cerebellum, while nothing abnor- 
mal was discovered in other organs. There are also striking examples in 
which the cause was located in the spinal cord. Thus Marshall Hall re- 
lates the following case communicated to him. A child with spina bifida 
was attacked with croup-like convulsions, whenever it lay so as to press on 
the tumor. 

Internal convulsions also frequently occur in rachitic softening and absorp- 
tion of the calvarium, since, when this is present, undue pressure occurs 
upon the brain, even by the weight of the head of the child upon the pil- 
low. 

In some patients there is evidently an hereditary predisposition to this 
disease ; those affected belonging to families in which there is a tendency 
to convulsive maladies. Thus Toogood relates that five infants of the 
same family were affected with spasm of the glottis ; and Reid relates, on 
the authority of Povvel, that of thirteen infants of the same parents only 
one escaped internal convulsions. 

The common predisposing cause is an excitable state of the nervous 
system, often associated with impaired general health. Hence the disease 
is more prevalent in cities, where anti-hygienic conditions abound, than 
in the country. Hence, too, the frequent improvement when the patient 
is removed to the pure and bracing air of the country. The use of in- 
sufficient food, or food of a bad quality, must for the same reason be con- 
sidered a cause, as it leads to impoverishment of the blood, and renders 
the nervous system more impressible. Facts mentioned by Reid and 
others show conclusively the influence of premature weaning, and the use 
of indigestible or otherwise improper aliment, in the production of this 
di^ea^e. 



476 INTERNAL CONVULSIONS. 

The causes enumerated above are for the most part predisposing ; oc- 
casionally they are the only apparent causes, since this disease sometimes 
occurs when the child is perfectly tranquil, even in the midst of quiet 
sleep, or when it is at rest in its mother's arms. In other cases, and 
more frequently, there is an exciting cause, often trivial. Anything that 
requires exertion on the part of the infant, or that excites strong emo- 
tions, may be a direct cause, as anger, or any of the violent passions ; so 
may even coughing, or, in rare instances, attempts to swallow. One 
author has known it to occur from excitement produced by examining the 
throat with a spoon. In a case in my practice, hereafter related, it oc- 
curred whenever the infant cried violently. It appears from the above 
facts that the etiology of internal convulsions is very similar to that of 
eclampsia. The same spasmodic muscular contraction may occur from a 
variety of causes. 

Anatomical Characters. — While, therefore, structural changes in 
various parts of the system may give rise to internal convulsions, this dis- 
ease, so far as ascertained, presents no anatomical characters, and must 
consequently be considered one of the neuroses. The lesions of the res- 
piratory apparatus, which are seen at post-mortem examinations, are due 
to the convulsions or are coincidences. Emphysema has sometimes been 
observed as a result, it is believed, of the spasmodic and irregular respira- 
tion. It was present in all of Herard's cases, and Rilliet and Barthez con- 
sider it common in those who die of this affection, although they did not 
observe it in any of their cases. Slight emphysema in the upper 
lobes is, however, a common lesion in feeble infants, whatever the disease 
of which they die. Therefore its occurrence in internal convulsions is 
probably more due to molecular change in the lungs, since these patients 
are cachectic, than to the irregular breathing, which is only momentary. 

In fatal cases of internal convulsions the blood is darker than usual, 
from an excess of carbonic acid ; the cavities of the heart and large ves- 
sels are sometimes engorged with blood ; but in other cases they contain 
no more than the normal amount. More or less passive congestion occurs 
in the internal organs ; and congestion of the cerebral vessels is some- 
times such that transudation of serum occurs. 

Symptoms. — I have said that the symptoms vary according to the seat 
and function of the muscles which are affected. There is generally pre- 
vious ill- health. The child is drooping, and is sometimes restless for days 
before the disease appears. Finally, if the muscles of the glottis become 
affected, the peculiar crowing sound is heard now and then during in- 
spiration. It is observed especially when the child is crying or is agi- 
tated. It may be loud and well-defined from the first, but in most pa- 
tients it comes on gradually, so that several days elapse before its full 
stridulous character is developed. The attacks are more frequent and 
severe at night, in or after the first sleep, than in daytime. 



SYMPTOMS. 477 

Under favorable hygienic conditions, the malady may pass off without 
becoming more serious. In other cases the paroxysms gradually increase 
in frequency and severity. The dyspnoea in the attack is such that the 
features are livid, the head forcibly retracted, and death seems imminent 
from apneea. In these severe paroxysms respiration often ceases entirely 
for a moment. When the spasm ends, a deep stridulous inspiration oc- 
curs, after which the breathing is natural. I have stated above that internal 
convulsions are often associated with those, usually tonic, but sometimes 
clonic, of the external muscles. In the tonic form, the thumbs are flexed 
across the palms of the hands, and sometimes are grasped by the fingers ; 
the great toes are adducted, and the other toes flexed. In severe cases, 
the hands, forearms, feet, and legs are also somewhat flexed and rigid. At 
first, the contraction of the external muscles is temporary, either corre- 
sponding with the internal spasm, or it is most intense at the time of the 
spasm, though commencing sooner and subsiding later. After a while, 
however, if the disease continue, the spasmodic action of the external mus- 
cles becomes more persistent. In severe cases, nearly ever} T inspiration is 
accompanied by the wheezing sound, and the paroxysms of dyspnoea are 
excited by trifling causes. Anything that suddenly disturbs the mind or 
body may bring on the attack, as anger, the impression of cold, or 
currents of air. Dr. West calls attention to the fact that an anasarcous 
condition is sometimes present, accompanied by albuminuria. 

If the convulsions affect other muscles, as the diaphragm or the pec- 
toral and abdominal muscles, which are concerned in the respiratory func- 
tion, while those of the larynx escape, respiration is irregular, or even 
suspended for a moment, but the stridulous laryngeal sound is absent, as 
there is no obstacle in the larynx to the entrance of air. In this form of 
the disease, the infra-mammary region may be strongly retracted during 
the paroxysm from tonic contraction of the diaphragm. In severe par- 
oxysms, whether the spasm be laryngeal or diaphragmatic, consciousness 
is nearly or quite lost, the features may be pallid, or, if respiration be 
suspended, may be more or less livid. There is no fever in simple cases. 
In the paroxysm there is often relaxation of the sphincters of the bowels 
and bladder, with involuntary evacuations. 

The duration of the paroxysm may be a quarter, a half or even a whole 
minute. Total suspension of respiration for even half a minute involves 
danger. In mild cases there may be but few paroxysms, and they slight. 
In other instances they occur in a severe form, almost daily for several 
weeks or even months. In the following case the muscles of the larynx 
were apparently not involved. The patient was scrofulous, and has since 
had scrofulous periostitis, with necrosis and exfoliation of the surface of 
the tibia. At the time of the internal convulsions there was also a scor- 
butic or hsemorrhagic cachexia. 

Case. — On the 28th of August, 1858, a German female infant, four- 



478 INTERNAL COXVl'L S I N S . 

teen months old, nursing, and having eight teeth, was suddenly seized 
with clonic convulsions. Uniformly delicate and pallid, she had been in 
her usual health till the age of twelve months, when she had a single 
convulsive attack, and from that date had remained Avell till August 27th,. 
when, without any premonitory symptom, she had a stool consisting of 
almost pure blood, black and offensive. On the morning of the 28th a 
similar evacuation occurred, and another in the afternoon immediately 
preceding the convulsion. Pulse 128, after the convulsion ; surface cool 
and pallid ; flesh soft, but no emaciation. Turpentine was prescribed in 
two-drop doses every two hours, and laudanum in one and a half drop 
doses, repeated sufficiently to insure quietude. 

On the 29th the pulse was 152. At 1 p.m. she had a general convul- 
sion, lasting about five minutes ; in the evening she had an evacuation simi- 
lar to those passed on the preceding day. The record for August 30th 
states : " Pulse from 150 to 160 ; up to this time has been playful, but 
is now drowsy, and, when disturbed, fretful ; manifests no desire for 
solid food, as before her sickness, but still nurses ; has taken up to this 
time thirty-two drops of turpentine. When she cries or frets, she has a 
spasmodic attack." This w T as the commencement of internal convulsions, 
with which this child was affected for several months. An opportunity 
was afforded of observing their character, for her excitement, when she 
was examined, was usually sufficient to produce them. After a succes- 
sion of short expirations, respiration ceased ; for a moment she was ap- 
parently insensible ; eyes closed ; face pallid ; no frothing at the mouth. 
The return of consciousness and respiration was without any laryngeal 
rale ; and after the attack she seemed as well as before. No external 
convulsion and no evacuation of blood occurred after August 31st. 

There was gradual improvement in her health, but she continued for 
many months pallid and irritable, and subject to attacks of internal con- 
vulsions. On the 11th of April, 1859, when twenty-two months old, she 
had another attack of general convulsions. The record made on that 
day is : " Has had internal convulsions (one or more paroxysms) almost 
every day since last August, brought on usually by crying when she is 
corrected in any way, or her wishes are refused." Again, on December 
1, 1859, it is stated : '- Has grown considerably since the last record, and 
appears to have recovered, except that at long intervals the spasms still 
occur." She took a preparation of iron, but her recovery seemed to be 
due more to the growth and development of the body and to hygienic 
than therapeutic measures. 

The general health in internal convulsions is more or less impaired, ex- 
cept in mild forms of the disease, in which the convulsive attacks soon 
cease. Pallor, or a sickly and cachectic aspect, irregular, usually consti- 
pated bowels, poor appetite, and moroseness or irritability of temper, are 
common symptoms of severe and protracted cases. 

Diagnosis. — This disease is easily diagnosticated, unless when its 
symptoms are masked by those of external convulsions ; it may then 
escape notice. Spasm of the glottis may be mistaken for spasmodic 
laryngitis, and vice versa. In some of the published cases this mistake 
appears to have been made. Spasmodic laryngitis is, however, so differ- 
ent not only in its nature, but in its clinical history, that a differential 



PROGNOSIS — TREATMENT. ±79 

diagnosis is not difficult. It is an inflammatory disease, and is attended 
with febrile reaction and a sonorous cough; it commences at night after 
the first sleep, and from exposure to cold- — particulars in regard to which 
it contrasts with true spasm of the glottis. 

Prognosis. — Modes of Death. — Statistics show great mortality in 
this disease. Dr. Reid, in a monograph on " Infantile Laryngismus, ' r 
states that of 289 cases which he collated, 115 died. Rilliet and Barthez 
met with one favorable case in nine unfavorable ; and Herard, one in 
seven. If the paroxysms be mild, infrequent, and dependent on a cause 
which can be easily removed, recovery is probable with proper treatment. 
The cause may, however, be such, even when the spasm is mild, that the 
case is necessarily unfavorable ; as when it is due to disease of the cere- 
bro-spinal axis. "We should not, however, in any case consider the patient 
entirely safe, since grave symptoms may suddenly arise, so as to change 
entirely the prognosis. Long and severe paroxysms, with lividity of the 
face, and symptoms of suffocation, indicate an unfavorable result. The 
same should be predicted also if the infant gradnally waste away, losing- 
appetite and strength, especially if the face be pallid and the pulse feeble. 

There are three modes of death in internal convulsions. The first is 
apncea. The infant dies suffocated in the attack. Respiration is first ar- 
rested, and then the pulse ceases, and at the autopsy the lungs and the 
cavities of the heart are found engorged with dark blood. Death may 
also result from the state of the brain. In such cases, passive congestion 
of the brain occurs from obstruction to the return of blood from this 
organ to the heart and lungs ; and if this congestion be not soon relieved, 
serous effusion also occurs. Death results from the congestion, and con- 
sequent oedema or dropsy. 

The third mode of death is from exhaustion. Repeated and severe 
attacks undermine the constitution; the infant gradually grows pallid and 
thin, and dies of inanition, or of some disease which this state induces. 

Treatment. — The treatment of internal convulsions has varied accord- 
ing to the theories which physicians have held in reference to its cause. 
Glandular enlargement is no longer regarded as a common cause, and 
therefore treatment directed to its removal is less frequently employed 
than formerly. The causes of internal convulsions are in part very simi- 
lar to those of eclampsia, and the remedies employed in the one affection 
are, in a measure, appropriate in the other. That dentition is sometimes 
a cause, is usually admitted ; and two cases, one of which occurred in my 
practice, and the other was reported to me, appeared to show that it may 
have a causative relation. The effect of dentition is especially observed 
in weakly infants, when several dental follicles are undergoing active 
evolution. Thus, in one of the cases to which I refer, five teeth pierced 
the gums in the course of two weeks ; after which no convulsive attack 
occurred. If, therefore, the gums are swollen, the propriety of scarifi- 



480 INTERNAL CONVULSIONS. 

cation should be considered, especially if the convulsions be so severe as 
to endanger life. 

In all cases of internal convulsions a careful examination should be 
made, in order to detect any appreciable source of nervous excitation. 
The condition of the digestive organs should be ascertained, and evacu- 
ants or other remedies prescribed if there be evidence of their derangement. 

Sometimes the alimentation of the infant is in fault. It is, perhaps, 
bottle-fed, and the stools have an unhealthy appearance. Attention should 
be given to the preparation of its food and the times of its feeding ; or, 
if it nurse, the mother or wet-nurse who suckles it should have plain but 
nutritious diet, live with regularity, and give the breast to the infant at 
regular intervals. If there be a torpid state of the intestines, Dr. Meigs 
recommends " castor oil and aromatic syrup of rhubarb rubbed up to- 
gether, three parts of the former and five of the latter. ' ' A simple enema 
answers well in such cases, and, in debilitated infants, this is preferable to 
medicine administered by the mouth. If diarrhoea be present, and it per- 
sist after the requisite changes are made in regard to the diet, remedies 
calculated to relieve it, and which are detailed elsewhere, should be em- 
ployed. Marshal] Hall states that he has ordinarily succeeded in curing 
the disease by attending to the condition of the gums and digestive 
organs. 

Since rachitis is a not uncommon cause, the child should be examined 
in reference to the rachitic manifestations, and if they appear the treat- 
ment appropriate for rachitis is required. 

In pallid and cachectic infants, tonics are indicated. The elixir of 
Calisaya bark in half-teaspoonful doses, three or four times daily, to an 
infant of one year, is an eligible preparation. The compound tincture of 
bark, or of gentian, or the two mixed, may be given instead of the Cali- 
saya bark. The preparations of iron are sometimes to be preferred, as 
the citrate of iron and bismuth, citrate of iron and quinia, the syrup of 
iodide of iron, or the wine of iron. To an infant of one year the syrup 
may be given in doses of three drops, the citrates in one-grain doses, and 
the wine in doses of one teaspoonful, every four hours. If the child be 
old enough, it may take iron in lozenges, as those of chocolate and iron. 

Antispasmodics, as assafcetida, valerian, and oxide of zinc, are often 
prescribed in this malady, but they are less efficacious than the general 
tonic measures which I have indicated. The salutary effect of bromide of 
potassium in eclampsia, and certain epileptiform attacks, certainly justi- 
fies the trial of this agent in internal convulsions, if they persist after the 
employment of invigorating measures. 

Hygienic measures are of the utmost importance. The infant should 
reside in dry and airy apartments, and should be kept much of the time 
through the day in the open air. Remarkable success sometimes attends 
this simple expedient, when medicines have entirely failed. In the Lon- 



CHOREA. 481 

don Med. Gazette, Jan. 14, 1865, Mr. Robertson, of Manchester, relates 
five severe cases in which this malady was cured by exposure of the in- 
fants several hours daily to a cool atmosphere. These cases were treated 
in the winter months, and were kept out-door, even during strong winds. 
Mr. Robertson has records of forty cases, all occurring between Decem- 
ber and April, while he has seen no case in the summer months. As the 
result of such extensive experience, this writer recommends " the free 
exposure of the infant out of doors, for many hours daily, to a dry, cold 
atmosphere, and if the air be dry, the colder the better." Dr. Marshall 
Hall's experience was similar. Says he : " The curative influence of 
change of air, and especially of the sea-breezes, is not less marked in this 
affection than in hooping-cough. " Mr. Robertson recommends also, as 
part of the tonic treatment, " free sponging of the body every morning 
with cold water." In February, 1867, I attended a nursing infant, five 
months old, with internal convulsions, the paroxysms being attended with 
lividity of the face, and, at times, tonic convulsions of the limbs. Among 
the remedies employed was bromide of potassium, but more benefit ob- 
viously accrued from keeping the infant much of the time in the open air, 
than from the medicines employed. The disease passed off in six or 
eight weeks. 

Unless the cause be of such nature that it cannot be removed, the above 
hygienic and therapeutic measures will, in a large proportion of cases, be 
followed by a satisfactory result. 

The mother or nurse may abridge the paroxysm by raising the infant, 
blowing upon it, sprinkling water in the face, or gently stroking it. Dr. 
Hall recommends tickling the nostrils with a feather, to produce respira- 
tion, or the fauces, to occasion vomiting, and thereby interrupt the par- 
oxysm. Anything which produces a sudden and profound effect upon the 
system may abridge the attack. This was effected in one case, in the 
practice of Dr. C. D. Meigs, by applying a cloth wrapped around ice 
over the epigastrium and the lower part of the sternum. The chief 
danger during the attack is from congestion of the brain, with effusion of 
serum or extravasation of blood. If the attack be severe, and the features 
congested, so that there is evident danger of such a result, cold applica- 
tions should be made to the head, derivatives used for the extremities — 
as sinapisms, or mustard foot-baths — and the bowels should be speedily 
•opened by enemata. 

CHAPTER XIY. 

CHOKEA. 

Chorea, or St. Vitus's or St. Guy's dance, is a neurosis, which is 
characterized by irregular and involuntary muscular movements, without 
loss of consciousness. The movements occur in the muscles of volition, 
31 



482 CHOREA. 

and there is probably no one of them that may not be engaged, though* 
some are more frequently affected than others. It is not known that any 
involuntary muscle is ever involved, though Sir William Jenner has ex- 
pressed the opinion that occasionally the papillary muscles of the heart 
are, so that, by their spasmodic contractions, they produce insufficiency 
of the mitral valve. This, according to him, affords explanation of the 
fact that, in certain instances, a mitral regurgitant murmur is heard, which 
disappears about the time that the external movements cease. It is rare, 
however, that a mitral regurgitant murmur, heard during chorea, ceases 
when the latter terminates, and it is not improbable that in such cases 
there is, after all, a lesion of the valve, due to recent endocarditis,, 
whether of a rheumatic or other origin. For a valve may be so thickened 
by recent inflammation as to cause a murmur, and after a few weeks or 
months the infiltrating substance be so absorbed that the murmur is no 
longer audible. If we admit the fact that cardiac bruits occasionally 
appear and disappear with chorea, this explanation seems to me more 
plausible than that of Jenner. Hillier says, in reference to this subject r 
tk My own experience leads me to doubt the existence of dynamic apex 
murmurs in chorea, that is to say, murmurs produced in hearts entirely 
free from organic change. If such murmurs ever occur, they are certainly 
rare. Organic murmurs of the heart, on the other hand, are common in 
chorea, and I am inclined to believe that organic disease of the heart often 
exists in chorea when there is no murmur." We shall see that this opin- 
ion is correct, by a case presently to be related. Hillier also calls atten- 
tion to the fact that choreic movements are irregular ; but a cardiac bruit 
occurring regularly and uniformly, if not due to organic disease, would 
require rhythmical contractions of the papillary muscles to produce it. 

In the class of children's diseases in the Bureau for the Relief of the 
Out-Door Poor in New York City, 6986 children were treated in the two. 
years and three months ending with March 31st, 1877. Of these cases 
82, or one in every 207, had chorea. The patients were all under the age 
of fifteen years. Statistics published by observers in Europe show that 
the relative frequency of this disease is probably about the same in the 
large European cities as in New York. Thus, according to Hillier, 
amongst 122,621 out-patients treated at the Hospital for Sick Children, in. 
London, 406, or 1 in 322, had chorea ; while of the in-patients 174 in 
5585, or 1 in every 32, were choreic. In the Parisian Hospital for Sick 
Children, of 84,968 admitted in twenty-one years, 531 had chorea, or 1 
in every 161. 

Age. — Chorea may occur at any period of life, but a large majority of 
the cases are in childhood. It is rare in infancy, and it rarely begins after 
puberty. Under the age of five years the proportionate number dimin- 
ishes, as we approach the time of birth. The youngest in the statistics of 
Hillier was three months. In 1870, in the Bureau for the Out-Door Poor r 



6 years 

and 
under. 

mitted, 81 


6 to 10 
years. 

237 


10 to 15 
years. 

104 


. 10 


61 


118 


2 


26 


16 


Under 3 3 to 5 
years, years. 

13 


5 to 10 
years. 

51 


10 to 15 
years. 

14 



CAUSES — S E X . ±83 

a child was presented for treatment, who the mother said had had chorea 
from birth, and in 1ST 7 I treated a young woman with severe general 
chorea, who, repeatedly questioned, uniformly said that she had had the 
disease, without any assignable cause, from the first week of her life, and 
her friends corroborated the statement. The following table exhibits the 
relative frequency of chorea at different ages : 



Children's Hosp., Lond., Hillier, none over 12 years admitted 

M. Rufz, 

Bureau for Out-Door Poor (prior to 1875), . 



Bureau for Out-Door Poor (since January 1, 1875), 



M. See collected the statistics of 531 cases occurring in the Children's 
Hospital, Paris, and from them concludes that the maximum frequency of 
chorea is between the sixth and tenth years. Only twenty- eight of his cases 
were under six years, the remainder, 503, occurring between the sixth 
year and puberty. 

Causes. — The rjrofession are nearly agreed in regard to certain causes 
of chorea, while there is a diversity of opinion in reference to others. It 
is admitted that in a large proportion of cases there is a neuropathic state, 
which antedates and predisposes to chorea. This state is often manifested 
in the family history by a proneness to affections of the nervous system, 
and in the individual by a highly excitable state of the emotions, so that 
he evinces joy, grief, or anger, from slight causes. 

All writers admit that there is often an inherited predisposition to 
chorea. In 27 of 48 cases, Radcliffe found that father, mother, brother, 
or sister had been or was the subject of one or other of the following 
disorders : paralysis, epilepsy, apoplexy, hysteria, or insanity. The chil- 
dren of parents who when young had chorea, or who exhibit prone- 
ness to ailments of the nervous system, are more liable to chorea than 
other children. Hence the fact sometimes observed, of different chil- 
dren in the same family becoming affected with chorea when they attain 
the age at which this disease ordinarily occurs. In one family in my 
practice, three girls at different times were affected. 

Sex. — The emotions are strong in girls, since in them the nervous sys- 
tem predominates, while the muscular power is weaker than in boys. 
Hence a partial explanation of the fact which statistics fully establish, 
that the proportion of choreic boys to girls is about in the ratio of one to 
two and a fraction. I have remarked, in this city,, the large proportion 
of cases in school-girls between the ages of six and twelve years ; the 
severe discipline and confinement of the public schools no doubt increas- 



484: C H O li E A . 

ing the strength of the emotions, and weakening the control of the will 
over the muscles. 

Proportion of Males to Females. 
27 to 73. Hughes's Digest of Cases in Guy's Hosp., 1846. 
138 to 393. M. See. 

50 to 94. Out-Door Department, Bellevue. 
276 to 499. Children's Hosp., Lond. West (Lumleian Lect.). 

481 to 1059 = 1 to 2.15. 

Uterine Irritation. — The peculiar changes occurring in the female at 
puberty constitute an important cause. Hence another reason of the excess 
of female cases. Dysmenorrhoea and pregnancy are causes of a large pro- 
portion of cases in the first years of puberty. In the male, on the other 
hand, the changes of puberty do not appear to increase the liability to the 
disease, directly or indirectly, and male cases, after the age of twelve 
years, are comparatively rare. Radcliffe states (Reynolds' s System of 
Med.) that after the ninth year, females are more liable to chorea than 
males, in the proportion of 5 to 2 ; while before the ninth year, the two 
sexes are equally liable to it. Carefully prepared statistics, however, not- 
withstanding the high authority of Radcliffe, show a preponderance of 
girls under the age of nine years, though not so great as over that age. In 
the Out-Door Department at Bellevue, of 35 patients under the age of ten 
years, 22 were girls, while of 20 from the age of ten years to sixteen, 15 
were girls. 

According to West (Lumleian Lect.), in 775 children with chorea, 
under the age of ten years, treated in the London Children's Hospital, 64 
per cent were girls. 

Anosmia. — Among the most common predisposing causes of chorea is 
anaemia. It is present in so large a proportion of cases, exhibiting itself 
by pallor of the countenance and other characteristic signs, that medicine 
designed to improve the quality of the blood are among the most valued 
remedies. The peculiar neuropathic state already alluded to, which needs 
only a slight additional cause for the development of chorea, is, no doubt, 
largely dependent on impoverishment of the blood, if it be not sometimes 
due entirely to it. Among the poor of a large city like New York, or in 
hospital practice, the proportion of anaemic cases of chorea is, for obvious 
reasons, much larger than would appear from general statistics. 

Rheumatism. — Dr. Copeland, M. Bouteille, and afterward M. Ger- 
main See, in a more extended monograph, directed the attention of the 
profession to rheumatism as a cause of chorea. Subsequent observations 
have established the fact that rheumatism, or the rheumatic diathesis, is 
so frequently present that it obviously sustains an important relation to 
chorea, though in what manner is not fully ascertained. This relation 
between the two is more frequently observed in some countries than in 



RHEUMATISM. 485 

others. In England and France, so large a proportion of choreic patients 
present the history of rheumatism either in themselves or family, that 
certain physicians of these countries believe that rheumatism is the most 
common cause of the disease. In Germany, on the other hand, accord- 
ing to Romberg, in the majority of cases no relation can be traced between 
chorea and rheumatism. Probably the largest number of choreic cases 
treated in one institution in this country is in the Bureau for the Relief of 
the Out-Door Poor, in this city ; and it has been our practice during the 
last few years to examine each patient for heart disease, and question the 
parents as regards rheumatism. Without referring to the exact statistics, 
I should say that perhaps half gave the history of rheumatism in them- 
selves or parents or had unequivocal signs of heart disease, so that all the 
physicians of the class fully accept the theory of the frequent causative 
relation of rheumatism and valvular disease to chorea. 

Various theories have been promulgated in explanation of the relation- 
ship of the rheumatic and choreic diseases. It has been suggested that 
chorea is due to rheumatism of the brain or spinal cord. This is simply 
an hypothesis, the truth or falsity of which can only be ascertained by 
carefully conducted necropsies ; but the theory appears improbable in 
view of all the facts. Another theory attributes chorea to the state of the 
blood which is present in those having rheumatism or the rheumatic di- 
athesis, as well as in certain other conditions. This theory is enunciated 
by Dr. Ogle, as follows: " Recognizing the frequent existence of these 
fibrinous deposits or granulations on the heart's valves in chorea, I should 
be much inclined to look upon these post-mortem appearances rather as 
results of some antecedent general condition of the blood, common also 
to the choreic condition. It is very freely recognized that this affection 
is frequently, in some way or other, connected with that condition of 
blood which obtains in what we call anaemia, or that existing in rheumatic 
constitutions. In both of these states we know that the fibrin of the 
blood is much in excess (as also it is in pregnancy, another condition 
looked upon as obnoxious to chorea") ; and in these states we know that 
the fibrin with which the blood is surcharged is very prone to be readily 
precipitated, either owing to its superabundance, or from other obscure 
and acquired properties . . . upon the heart's walls or valves. 
May not this hyperinosis be the explanation of the coincidence alluded 
to?" [British and Foreign Med. Chir. Rev., January, 1868) — namely, 
the occurrence of chorea in those affected with rheumatism. Others still 
hold that chorea is the result of the heart disease, and not directly of 
rheumatism, occurring when the heart is affected from other causes, as well 
as when the lesion has a rheumatic origin. This theory is plausible, and 
probably to a certain extent correct. Heart lesions, observed in children, 
result from scarlet fever in a considerable proportion of cases, though it is 
true that the endocarditis and pericarditis of scarlet fever are believed often 



486 CflOKEA. 

to have a rheumatic origin, occurring, in some instances, from scarlatinous 
rheumatism, but in other cases from scarlatinous uraemia. Occasionally, 
also, the heart disease appears to have occurred independently of both 
rheumatism and scarlet fever. Thus in a fatal case of chorea with valvu- 
lar disease, related to the London Pathological Society, April 6, 1869, 
the child was always healthy up to the present illness (chorea), and there 
was no history of rheumatism in the family. The more observations ac- 
cumulate, the more important does heart disease in itself appear as a cause 
of chorea. In nearly all recorded cases of fatal chorea, which were sup- 
posed to be due to rheumatism, and in which post-mortem examinations 
were made, endocardial and usually valvular disease has been found. We 
shall see that certain eccentric causes of irritation aid in producing chorea, 
and may not the valvular disease, or the endocarditis which causes the 
valvular lesion, operate in a similar manner as a cause ? We know that in 
the adult severe cardiac disease often profoundly affects the nervous sys- 
tem, perhaps in consequence of the irregular and embarrassed circulation ; 
and certainly in the child a similar cause would be likely to produce a 
more decided effect. 

But there is an ingenious theory which attributes chorea to minute em- 
boli detached from vegetations on the valves, and arrested by capillaries in 
the corpora striata, or other portion of the cerebro-spinal axis. Since at- 
tention was directed to this matter, emboli have been found in one case 
in the medulla oblongata, although this portion of the spinal axis ap- 
peared healthy to the naked eye. Further observations are necessary in 
order to determine how much truth there is in this theory ; but it seems 
probable, for reasons to be stated, that if capillar}* embolism do cause 
chorea, it is only in a limited number of cases, and that therefore those 
British observers who regard it as the common cause, have been led into 
error by the large proportion of choreic cases which are complicated by 
valvular lesions in their climate. 

That embolism is not a common cause, if indeed a cause at all, appears 
probable from the following facts : First. In many cases of chorea there 
are no vegetations, or other appreciable lesions, which could give rise to 
emboli. Secondly. Most patients recover, and some speedily, by treat- 
ment, which we would not expect if the cause were embolism. Thirdly. 
Embolism is not infrequent in the cerebral vessels of the adult, without 
the occurrence of chorea. Indeed, the conditions which produce embo- 
lism are much more common in adults than in children,, while the reverse 
is true as regards the liability to chorea. Fourthly. Pogs sometimes 
have chorea, but the injection of minutely divided fibrin or other sub- 
stance in the veins of the dog is not followed by chorea as one of the 
phenomena. Fifthly. Were capillary emboli the cause, we would ex- 
pect to find an occasional embolus in the larger vessels of the brain, so as 
to be appreciable to the naked eye ; but I find no examples of this in all 



E H E U M A T I S M . ±87 

the recorded autopsies which I have been able to consult. Moreover, it 
seems improbable that capillary embolism, when producing- no lesion ap- 
preciable to the naked eye, would so arrest the circulation, and disturb 
the function of the brain or spinal cord, as to cause chorea, for the ill 
effects of such an obstruction would be likely to be obviated by the 
numerous anastomoses. 

In 1877 the unusual opportunity occurred., in my asylum practice, of 
determining whether there are any fixed anatomical characters in the cere- 
brospinal axis in chorea ; in other words, whether chorea is a neurosis, 
as we have designated it in our definition, and the case is so interesting in 
other respects that I will relate it entire. 



Charles, a foundling, born Oct. 15, 1874, was received in the New 
York Foundling Asylum soon after his birth. When two weeks old he was 
removed to a family in the city to be wet-nursed. His health continued 
good till the age of three months, when he had bronchitis and keratitis, 
the former mild, and lasting only a few days, but the latter continuing 
nearly two months, being attended by moderate injection of the conjunc- 
tiva, with some purulent discharge, which caused adhesion of the eyelids 
during sleep. From this time he remained well, with the exception of a 
slight attack of dysentery, till the age of about nine and a half months, 
when he began to have febrile symptoms. In the morning hours he 
seemed in tolerable health, but at midday, or a little later than midday, 
of each day, he was observed to have slight irregularity or embarrassment 
of respiration, and lividity, with coolness of the extremities, which state, 
supposed at the time to be the algid stage of a somewhat irregular inter- 
mittent fever, lasted from one to two or three hours, and was succeeded 
by febrile movement, which continued during the remainder of the day ; 
sometimes the fever abated in perspiration. 

On August 4, 1875, a few days after the commencement of these irreg- 
ular febrile symptoms, Charles was brought to the dispensary of the insti- 
tution for treatment, and Dr. Reid, who was on duty that day, carefully 
examined the case, and prescribed the sulphate of quinia. This medicine 
continued a few days relieved the symptoms, but every four to six 
weeks, for more than a year, these febrile attacks returned, and were uni- 
formly relieved by the same medicine. In other respects the patient had 
the usual health. 

On or about February 1, 1878, the nurse noticed that Charles had what 
she designated " spells of trembling," in which he seemed excited and 
feverish, and which were sometimes attended by or followed by perspira- 
tion. In the course of another week the irregular muscular movements 
became more marked and constant, and they increased in severity till near 
the time of the admission of the patient into the asylum, about March 
1st. The nurse had noticed in February slowness and some difficulty of 
micturition, and Dr. Reid examined him with a catheter for calculus, and 
also his prepuce for any source of irritation, but nothing abnormal was 
discovered, either in the condition of the bladder or the external organs. 
In the latter part of April, the chorea had become so severe, that irregu- 
lar muscular action occurred in all the limbs, and in the muscles of the 
-eyes, producing such grimaces and contortions with strabismus, that the 



488 CHOREA. 

woman with whom he was boarding became alarmed, and returned him 
to the asylum, stating that he had become crazy. 

On March 12th my attention was first called to this child, when I made 
the following entry in my note-book : " Family history unknown ; no 
history of rheumatism in patient's case, he may and may not have had 
it ; heart sounds normal ; pulse 104 ; all the limbs and the muscles of the 
face, eyes, and eyelids involved in choreic movements, which continue 
constantly except during sleep. The patient cannot walk or stand with- 
out support ; appetite good, apparently better than in health, for he eats 
every kind of food handed to him, and carries the food with his own hand 
to his mouth, although these movements are very irregular and jerking. 
Three drops of Fowler's solution ordered after each meal. 

March 17 th. — Condition not much changed, but perhaps slight im- 
provement ; in addition to other choreic movements the eyes twitch spas- 
modically ; pulse 84 ; temperature 98-J- ; bowels regular ; no cough ; 
appetite good. Increase medicine to five drops. 

30 th. — The urine examined since the last record was found very pale 
and abundant ; its specific gravity low, 104, without albumen. When an 
equal quantity of nitric acid was added to it, after twelve hours crystals 
of nitrate of urea occupied about one half of the volume of the urine. 
The patient's sleep is quiet, but the choreic movements recommence as 
soon as he awakens, but in a milder form ; is able to walk without sup- 
port, but with unsteady gait. My term of service ended March 31st. On 
the following day, laryngo-tracheitis was suddenly developed, ending 
fatally in forty-eight hours, at the age of two years five and a half 
months. 

Autoiosy, April 4th. Slight oedema about the aperture of the glottis ; 
general and intense redness of mucous membrane of larynx, trachea, and 
bronchial tubes, as far as they can be traced, posterior portions of lungs 
greatly congested. The heart, lungs, brain, with one eye attached to it 
by optic nerve, and the entire spinal cord were sent to Prof. Francis Dela- 
field, for microscopic examination. They were, as soon as removed, 
placed in a solution of bichromate of potassium. The following is a brief 
statement of the examination, which was thoroughly made. 

Microscopic Appearances. By Prof. Francis Delafield. Brain — 
presented no change apparent to the naked eye, except a considerable de- 
gree of congestion. It was hardened in bichromate of potassium and chro- 
mic acid. Minute examination of the convolutions of the brain, the large 
ganglia, the cerebellum, the pons Varolii, and the medulla oblongata 
showed nothing except a uniform filling of the vessels with blood, as if 
they were injected. There were no apoplexies, no changes in the walls 
of the vessels. 

Spinal cord — appeared to be entirely normal. 

The Heart. — The auricles and ventricles were of normal size. The 
aortic valves were atheromatous, and somewhat rigid ; the mitral valves 
were thickened and insufficient ; the endocardium of the left ventricle was 
thickened. 

The Lungs. — The capillaries in the walls of the air-vesicles were dilated, 
and there was an increase of epithelial cells within the air vesicles. 

In this case there seemed to be no lesion associated with the chorea ex- 
cept the organic disease of the heart, and the changes in the lungs, sec- 
ondary to this condition of the heart. 

The above microscopic examination was made with sufficient minute- 



FRIGHT — IMITATION. 489 

ness, and it is seen that no emboli were discovered, and no lesion of the 
eerebro-spinal axis except congestion, which was attributable to the mode 
of death, namely, by obstructed respiration. Moreover it will be recol- 
lected that there were no cardiac bruits, and apparently not sufficient 
roughness of the edge or surface of the valves to cause precipitation of 
fibrin, which would be necessary in order that emboli should form. 

Fright. — A not infrequent exciting cause of chorea is sudden and pro- 
found emotion, especially fright. All statistics give fright as the cause 
of a certain proportion of cases, though there are usually other potential 
co-operating causes, as anaemia or valvular disease. Fright was stated as 
the cause of chorea in 31 of the 100 cases occurring in Guy's Hospital, 
reported by Hughes, or in nearly one in three. But the statistics of 
other observers do not give so large a proportion of cases originating in 
this way. Chorea may commence withm a few hours after the fright, or 
not till the lapse of several days (eight or ten). If several weeks have 
pacsed since the fright, as in some reported cases, the chorea is probably 
due to other causes. In rare instances, chorea is said to have been caused 
by sudden and excessive joy. 

Imitation. — Under unusual circumstances, especially in a state of great 
mental excitement, imitation has been known to cause a form of chorea. 
Hecker describes an epidemic of it, occurring in the middle ages, and 
spreading through villages. In modern times it is rare that chorea orig- 
inates from this cause, nevertheless occasional examples have been re- 
corded. 

But the disease which occurs from imitation differs from the ordinary 
form, and has been termed chorea major ; while the chorea which is the 
subject of this article is sometimes designated, in contradistinction, chorea 
minor. 

In chorea major the patient leaps, dances, or whirls like a top. It has 
its origin commonly in religious excitement, and spreads by imitation 
almost in the manner of an infectious disease. The epidemic of the mid- 
dle ages was a chorea major. I have not been able to find any account of 
cases spreading by imitation, in modern times, which were not examples 
of the same form of chorea. Thus in the Edin. Jour, of Med. and 
Surg., for July, 1839, there is a clear description of chorea major, oceur- 
ring successively in five children in the same family. Dr. Dewar, the at- 
tending physician, states that one of the children whom he was called to 
see was sitting near the fireplace, when her head dropped on her chest, 
and she appeared to doze some minutes. In the meantime the respira- 
tion became a little accelerated, the face altered and flushed, the eyes 
wild. In less than one minute she bounded from one extremity of the 
apartment to the other, leaping over chairs, a chest, and then throwing 
herself upon the floor ; she attempted to stand upon her head, rolled 
upon the floor, and then, rising, ran with extreme swiftness in the room. 



490 CHOREA. 

till she finally fell again on the floor, where she remained motionless some 
minutes. Then, recovering, she noticed those who surrounded her, and 
asked of her sister a toy, which she had allowed to fall. The whole par- 
oxysm lasted twenty minutes. 

Obviously, the symptoms of chorea major differ materially from those 
of chorea minor, and it is a question whether it should have the same 
generic name. It is a curious and interesting disease in its psychical and 
pathological aspects, but it is so rare in modern times that a knowledge 
of it is of little practical importance. 

Intestinal Irritation. — In rare instances intestinal worms cause cho- 
rea, though in these cases there have usually been some co-operating 
causes. The following is an example, related by Mr. Ogle (Lond. 
Medico -Chir. Rev., Jan., 1868) : " Ellen L., 9 years old, had been under 
treatment about a month with chorea, rheumatism, and worms. She had 
not slept in four days, and there was constant spasmodic movement of the 
body and face. Her general condition was very unpromising. As she 
had passed portions of a tapeworm at intervals during the last three 
months, one drachm of the oleum filicis maris was administered in muci- 
lage, which caused the expulsion of the entire worm. From that time 
she fully and rapidly recovered from the chorea, though a mitral murmur 
remained." 

Lesions of Brain and Spinal Cord. — Although we reject the theory 
that cerebral emboli are the common cause of chorea, and believe that in 
a large majority of cases there are no cerebro-spinal lesions, nevertheless 
experiments, and also occasional cases, establish the fact that if not true 
chorea, at least choreiform movements now and then result from a struc- 
tural affection of the nervous centres. 

Experiments on certain of the lower animals demonstrate that irregular 
muscular movements may be produced by traumatic injury of certain 
portions of the cerebro-spinal axis, as the corpora quadrigemina, crura 
cerebri, pons Varolii, crura cerebelli, thalami optici, parts of the medulla 
oblongata, and the upper portion of the spinal cord. Pressure on the 
projecting part of the medulla oblongata of an acephalous monster also 
causes convulsive movements. At the meeting of the New York Acad- 
emy of Medicine, April 20, 1871, Professor Post related the case of a 
child who was struck with a billet of wood, over the occiput, and chorea 
followed, due, in all probability, to the injury of the brain which re- 
sulted. 

If irregular muscular movements, choreic or choreiform, result from 
traumatic injury of certain portions of the nervous centres, may they not 
also occasionally occur from lesions of the same parts produced by dis- 
ease ? Sir Benjamin Brodie relates the case of a choreic girl, dying in 
St. George's Hospital (London Lancet, Dec, 19, 1840), in w 7 hom, after a 
•careful post-mortem examination, the only morbid appearance observed 



ANATOMICAL CHARACTERS. 491 

was a tumor the size of a hazel-nut, connected with the pineal gland. 
Dr. Broadbent described another case before the London Pathological 
Society (vol. xiii. page 246, Transactions), in which a tumor was found 
arising from the centre of the spinal cord ; and Chambers one in which 
tubercles were imbedded in the cord. Romberg quotes from Frerichs a 
case in which the medulla oblongata was pressed upon by an enlarged 
•odontoid process ; and Dr. Aitken {Glasgow Med. Jour., vol. i.) one in 
which the specific gravity of the thalamus opticus and corpus striatum 
was greater on one side than on the other. Rilliet and Barthez relate 
other similar cases, and add : " We may conclude, from these different 
eases, that there exist two species of chorea : tbe one essentially a simple 
neurosis, while the other depends on an alteration of the encephalo-rachi- 
dian system. In a word, it is of chorea as of convulsions, that it is 
sometimes idiopathic, sometimes symptomatic." Still, the cases in 
which it is symptomatic are so few r , that it is proper to consider chorea, 
as it ordinarily occurs, one of the neuroses until the microscope detects 
some anatomical cause in the cerebro-spinal system of which we are now 
ignorant. 

Anatomical Characters. — We have seen that chorea has no certain 
anatomical characters. Lesions are sometimes present, which probably 
sustain a causative relation to the disordered muscular action, and others 
are sometimes observed which are neither a cause nor result, their pres- 
ence being a coincidence. But there are two lesions which, though often 
absent, have been observed in so large a proportion of fatal cases that 
they are justly regarded as an occasional result when chorea is severe. 
Dr. Hughes, of London, collected records of the post-mortem appear- 
ances of 14 cases, wdth the following result as regards the cerebro-spinal 
axis : Brain, 14 cases : healthy, 4 cases ; only congested, 3 cases ; soft- 
ened in part or entirely, 6 cases (some of these also congested). In 
some of these cases those occasional results of congestion, namely, trans- 
udation of serum and extravasation of blood, in greater or less quantity, 
were also observed. Spinal cord : healthy, 3 cases ; congested, 2 cases 
{one slightly, in the other the engorged vessels were large and numerous) ; 
softening in medulla oblongata, 1 case ; softening opposite fourth and 
fifth vertebra?, 12 cases. In one there was soft, in another firm adhe- 
sion of the spinal meninges, and in one it is stated that the rachidian fluid 
was opaque. Of sixteen fatal cases of chorea occurring in St. George's 
Hospital, "congestion (more or less complete) of the nervous centres 
(brain or spinal cord, or both) was met with in six cases." There was 
softening of certain parts of the brain in one case, and of the spinal cord 
in another. (Ogle, Brit, and For. Medico.- Chir. Rev., Jan., 1868.) 
Other statistics of the anatomical character of fatal chorea correspond, in 
the main, with those of Hughes and Ogle. These lesions are probably 
not present in ordinary cases, occurring only when the choreic movements 



492 CHOREA. 

are so severe that the patient is deprived of needed repose, and the im- 
portant functions of the economy, as the circulation and nutrition, are 
seriously disturbed. 

The post-mortem examination of other parts besides the cerebro -spinal 
axis furnishes a negative result, if we except such affections as have been 
ascertained to act as causes of chorea. What portion of the nervous cen- 
tre is chiefly involved in chorea is uncertain. Some, as Sir Benjamin C. 
Brodie [London Lancet, Dec. 19, 1840), consider chorea a disease of the 
nervous system generally, while others have attributed it to disease or dis- 
order of a certain part, as the corpus striatum, cerebellum, etc. Finally, 
it is stated that, in late experiments on choreic dogs, the movements do 
not cease when the spinal cord is severed from the brain, nor also on 
division of the posterior roots of the spinal nerves. (Legros et Onimus, 
Rech. sur les mouvements choreiformes du chien, Acad, des Sci., 9 Mai, 
1870, Lyons Med. Jour., June 5, 1870.) In these cases, therefore, the 
part of the axis which is in fault would awear to be solely the spinal 
cord. 

Symptoms. — Chorea is partial or general. It is partial when it affects 
a few muscles, or groups of muscles, as those of one arm, the face or 
neck, or of one eye. It is designated general, when all the limbs, and 
certain of the muscles of the face and trunk, are involved. Statistics 
show that partial chorea occurs more frequently on the left than on the 
right side, and in general chorea the movements on the left side are apt 
to predominate. The commencement is usually gradual. Even when 
finally chorea becomes general, certain muscles only are affected in the 
commencement in ordinary cases. The child in whom this disease is 
about to begin is observed to be fretful and impatient from slight causes, 
and the irregular muscular action at first is apt to be misunderstood by the 
parents, who reprimand him for his supposed fidgety habit. In excep- 
tional instances, especially when the cause is a sudden and profound emo- 
tion, the commencement is abrupt, and the disease is severe and general 
from the first. 

In a majority of cases the muscles which are primarily affected are 
those of the face, neck, fingers, or hand on the left side. Sydenham 
erred, unless the clinical history of chorea has changed during the last two 
centuries, when he stated as the common fact that a tottering gait is its 
first manifestation ; but now and then such a case does occur. Wherever 
the choreic movements first appear, other muscles are soon involved, so 
that in the course of a few weeks, sometimes of a few days, all the mus- 
cles that participate are engaged. 

A muscle affected by chorea alternately contracts and relaxes, but less- 
forcibly and rapidly than in eclampsia, and the movement is partly con- 
trolled by volition. This produces an unsteady and tremulous action of 
the part, whether a limb, the neck or face ; which at once arrests atten- 



SYMPTOMS. -±93 

tion, and indicates the nature of the disease. The result is similar, as 
regards the muscular action, whether the patient wills a movement, or 
attempts to control those which chorea produces. 

If the case be of ordinary severity, the movements continue with but 
momentary intermissions, except during sleep, when they ordinarily cease. 
In grave cases patients are often deprived of the proper amount of sleep, 
in consequence of the severity and persistence of the muscular action, and 
in exceptional instances, especially when the result is fatal, the movements 
continue in sleep, but the sleep is not sound, and is frequently inter- 
rupted. In profound sleep, the muscles are probably always in repose. 

The older writers have left us graphic descriptions of those diseases 
which have striking external manifestations, though often with somewhat 
of exaggeration. Sydenham says of chorea : " The patient cannot keep 
it (his hand) a moment in the same place ; whether he lay it upon his 
breast, or any other part of his body, do what he may, it will be jerked 
elsewhere convulsively. If any vessel filled with drink be put into his 
hand, before it reaches his mouth, he will exhibit a thousand gesticula- 
tions, like a mountebank. He holds the cup out straight, as if to move it 
to his mouth, but has his hand carried elsewhere by sudden jerks. Then, 
perhaps, he contrives to bring it to his mouth, and if so, he will drink the 
liquid off at a gulp, just as if he were trying to amuse the spectators by 
his antics !" 

In severe general cnorea a similar description is applicable to the move- 
ments of the legs and features. Grimaces and distortions of the features 
occur, while the gait is halting and unsteady, or it is impossible to walk, 
and the patient lies or sits. The speech is slow, thick, and indistinct, in 
consequence of the muscles of the tongue and larynx becoming engaged, 
and even mastication and deglutition are rendered difficult. The imperfect 
speech in chorea is attributed partly, however, to the mental state in 
severe protracted cases. Chorea, except when mild, is accompanied by 
other symptoms referable to the nervous system. More or less impairment 
of the mental faculties occurs in chronic cases when severe, exhibiting 
itself in dulness or apathy. The countenance sometimes presents in 
aggravated cases almost the appearance of idiocy. The muscles, instead of 
becoming hypertrophied, and more powerful by their frequent contrac- 
tion, grow softer, more flabby, and weaker. Indeed, a partial paralysis 
sometimes results, so that a degree of numbness is experienced in the 
affected part, and the limb when raised cannot be sustained. Pain is not 
a symptom of chorea, but fugitive rheumatic or neuralgic pains are some- 
times experienced. Derangement of the digestive function, exhibited by 
a poor or capricious appetite, constipation, etc., are common. 

The urine of choreic patients has been examined by Drs. 'Walsh, Ford, 
Bence Jones, Handfield Jones, Radcliffe, and others, and its elements 
have been found in most cases to vary from their normal quantity. Dr. 



494 CHOREA. 

Handficld Jones read a paper before the Clinical Society of London, in 
1871 (London Lancet, July, 1871), on two cases of chorea in which he 
had made careful chemical analyses of the urine, with the following* 
result : During the height of the disease the amount of the urine was 
much in excess of what it was when the disease had ceased ; the amount 
of urea excreted during the choreic period was enormous ; the amount of 
phosphoric acid excreted when the choreic symptoms were at their maxi- 
mum was excessive, but the quantity was less than the average during 
convalescence ; a moderate amount of uric acid during the disease, but 
none upon recovery. 

Prognosis — Course. — Chorea, though obstinate and often incurable in 
adults, usually terminates favorably in children in three or four months. 
Bouchut considers its ordinary duration at from thirty to fifty days, 
which is certainly shorter than the average duration in this country, ex- 
cept as the disease is materially abridged by treatment. The same author 
states that it may continue only a few days, as he has observed in cases 
which occurred during convalescence from scarlet fever. But tremulous- 
ness of the muscles occurring in the state of weakness following a grave dis- 
ease, and abating as the general health is restored, I should not consider 
as properly choreic, any more than that occurring from over-fatigue. As 
the choreic movements gradually increase in the initial period till a certain 
maximum is reached, so their decline is gradual. There are temporary 
variations also throughout the disease as regards the extent of the move- 
ments, which are aggravated by mental excitement, bodily fatigue, certain 
functional derangements, especially of digestion, and sometimes from 
causes which are not apparent. 

Though, as a rule, chorea in children ordinarily terminates favorably 
under different, and even injurious modes of treatment, there are excep- 
tional cases. Romberg relates the history of a patient who died at the 
age of seventy-six years, having had chorea since the age of six years. 
In chorea limited to a few muscles, or a group of muscles, the prognosis 
is more doubtful than when it affects a large number, since in the former 
case the cause is more apt to be some lesion of the cerebro-spinal axis. 
Thus chorea involving only certain muscles of the neck or of the eyes is 
sometimes due to this cause, and is then very obstinate. 

Again, observations demonstrate that chorea, when at first in all proba- 
bility strictly a neurosis, but of a protracted and grave character, may 
oive rise to a central organic disease. This is the course of most of the 
fatal cases, congestion, softening, or other lesion occurring over a greater 
or less extent of the nervous centres. Rad cliff e has known cerebral men- 
ingitis to supervene in two instances. With the occurrence of a lesion of 
the cerebro-spinal axis new symptoms arise, such as headache, convul- 
sions, delirium, and paralysis, and the choreic movements cease or con- 
tinue, according to the nature of the lesion. 



DIAGNOSIS— TREATMENT. 495- 

Chorea, like certain other diseases, either of a nervous character, or 
having a nervous element, is more or less modified by intercurrent inflam- 
matory and febrile affections. The oft-quoted expression from Hippo- 
crates, febris accedens solvit spasmos, observations show to be founded in 
fact, the most frequent example of which occurs in pertussis. In chorea 
the movements, as a rule, are either rendered milder or they cease as 
long as the febrile excitement continues ; but there are exceptions, and 
the subsequent course of the disease is not modified. 

Diagnosis. — That is not difficult in ordinary cases. The irregular 
movements, with consciousness preserved, enable us to make a diagnosis 
at sight. In its commencement, and when it continues in an unusually 
mild form, chorea might be overlooked by the physician, as it often is by 
the parents, the movements being attributed to a fidgety habit ; but 
medical advice is seldom sought till the movements are so pronounced 
that it is impossible to err, except through gross ignorance or careless- 
ness. 

It is important to determine when chorea merges in an organic disease,, 
and also whether there is a local cause of the chorea. A careful and in- 
telligent study of the symptoms and history of the case is requisite in 
order to a correct diagnosis in these particulars. 

Treatment. Regimenal. — As chorea in a large proportion of cases oc- 
curs in a state of anaemia, and the vital forces are ordinarily more or less 
reduced, obviously the regimen should be such as invigorates the system. 
Fresh air and outdoor exercise, active or passive, according to circum- 
stances, with the avoidance of undue excitement, are requisite ; and the 
diet should be nutritious, but plain and unirritating. The various functions 
should be preserved so far as possible in their normal state. In exceptional 
instances, when the choreic movements are violent, the patient should He 
in bed, and the muscular action, if so constant and excessive as to deprive 
him of the requisite sleep, should be restrained by light and well-padded 
splints. 

Medicinal. — Sometimes among the co-operating causes is one of a local 
nature, which is susceptible of removal, as a carious and painful tooth,, 
intestinal worms, etc., and measures calculated to effect this are obviously 
required. Allusion has already been made to a case in which the em- 
ployment of the oleo-resina filicis and the expulsion of a tapeworm 
effected a speedy cure. 

The remedy which has been most employed in chorea, and which in 
consequence of the anaemia is plainly indicated in a large proportion of 
cases, is iron. It does not interfere with the employment of other reme- 
dies which have a more specific effect. Nearly all the ferruginous prep- 
arations have been prescribed in different cases with benefit. Radcliffe 
gives the preference to the iodide of iron, believing that iodine, as well as 
iron, exerts a curative influence. I have of late inclined to the use of the 



496 CHOREA. 

ammonio-citrate, as it is easy of administration in simple syrup, and is well 
tolerated. 

But iron must not be regarded as the main remedy, but rather as an 
adjuvant. Observations during the last few years in both continents have 
more and more established the claims of arsenic to be regarded as the most 
efficacious of all medicinal agents in the treatment of chorea. Properly 
administered, it abridges, in my opinion, the duration of this disease more 
certainly than any other agent, and within a few days begins to modify 
the choreic movements in the severest cases. It is conveniently given in 
Fowler's solution. It is better tolerated by children than adults, and 
should be administered to them in a larger proportionate dose. A child 
of eight years can take five drops, diluted in water, three times daily after 
eating, and the dose may be increased if needed to eight drops. I have 
seldom observed any gastric irritability or other unpleasant effect from 
its use, but if such occur, it should, of course, be suspended for a time. 

While not hesitating to recommend iron and arsenic as superior to all 
other medicines in the treatment of chorea, it is not proper to ignore the 
opinions of other members of our profession, who have had ample ex- 
perience and recommend other agents instead. 

Trousseau gave the preference to strychnine, increasing the doses in 
some cases until it began to produce its poisonous effects. 

Professor Hammond (Diseases of the Nervous System, page 617) says : 
" My main reliance is on strychnia, which, I think, should be given in 
gradually increasing doses, somewhat after the manner recommended by 
Trousseau. . . . This plan of treatment certainly shortens the dura- 
tion of the disease very materially, and causes great improvement in the 
general health of the patient. Sometimes the effect is so well marked, 
and is so immediate, that it is not necessary to increase the doses to the 
extent of causing muscular cramps, but generally the full therapeutical 
-effect of the drug is not obtained till the calf of the leg or the nucha has 
slight tonic spasm. I have never seen the slightest ill-consequence follow 
this mode of treatment, and the doses are increased so gradually that, 
with careful watching, danger need not be apprehended." Dr. Ham- 
mond has treated thirty-two children with this agent without a single 
failure. 

But as chorea terminates favorably with smaller and safe doses, even if 
the time required be longer, it does not seem proper to recommend its em- 
ployment to the extent of producing physiological effects for general prac- 
tice. Bouchut, speaking upon this point, says : " But, with these precau- 
tions, strychnia is extremely dangerous, for I have seen, at the Hopital des 
■ Enf ants Malades, a young girl of thirteen years die in tetanus," pro- 
duced by an increased dose of this drug (article on Chorea). Dr. West, 
in his Lumleian Lectures, also says : " I have seen one instance in which 
its employment, while it failed to benefit a somewhat severe case of 



TREATMENT. 497 

chorea, was followed by two attacks of violent tetanic convulsions, which, 
nearly proved fatal ;" and he adds, " The twitching of the limbs of itself 
prevents our becoming aware of the dose being excessive, and a child's 
inability to describe its sensations deprives us of another." For such 
reasons, Dr. West does not favor the employment of this agent. Still, 
any agent may be given in an overdose, and it is not difficult to prescribe 
strychnia in a dose which will be efficient and yet safe for children at 
the age at which chorea ordinarily occurs. I have employed bromide of 
potassium in a few cases, but with so little benefit that I am not inclined 
to continue its use for this disease. Others have not been more successful. 
However efficacious the bromide may be in epilepsy, it does not appear 
to be a remedy for chorea. 

Cimicifuga, first employed by Jesse Young of this country, is highly 
esteemed by Philadelphia physicians in the treatment of chorea. I have 
employed the fluid extract in doses of half a drachm, increased to one 
drachm, for a child from six to ten years of age, and though it benefits 
some cases, it has no appreciable effect either in moderating the move- 
ments or abridging the duration of others. 

Ether, asafcetida, valerian, musk, the oxide and sulphate of zinc, tur- 
pentine, tartar emetic, opium, and numerous other remedies, have been 
recommended, and some of them have seemed useful in certain cases. In 
this city sulphate of zinc has been frequently employed as a remedy 
for chorea, and in gradually increasing doses till more than twenty grains 
were administered three times daily, but it has not appeared, so far as I 
have been able to ascertain, to exert any marked influence either on the 
severity or duration of the choreic movements. Justice, however, requires 
us to state that Dr. West, who has written recently on the nervous dis- 
orders of children, thinks that it has been beneficial in certain cases in 
which he has employed it, and regards it on the whole as the best remedy. 

Radcliffe, who has had ample experience in the treatment of nervous 
affections, writes : " In an ordinary case of chorea the plan of treatment 
which I have now adopted as a rule for some time is to give cod-liver oil, 
in conjunction with hypophosphite of soda, making the draught contain- 
ing the latter salt the vehicle for the administration of the cod-liver oil." 
Sometimes camphor or the sesquicarbonate of ammonia is added. Of 
more than thirty cases treated in this way, the average duration was under 
three weeks. Radcliffe began to prescribe these remedies on theoretical 
grounds, believing that phosphorus and cod-liver oil were required to 
restore " nerve tone," and the result of this treatment has certainly been 
such as to commend it to the profession. To children he gives from five 
to eight grains of the hypophosphite of soda three times daily. 

In those severe cases in which the choreic movements prevent the 
proper amount of sleep, a moderate dose of hydrate of chloral may occa- 
sionally be advantageously administered. 



498 INFANTILE PARALYSIS. 

Electricity has been many times employed in the treatment of chorea r 
and though some, chiefly electricians, believe that it has a curative effect, 
others, and the majority, fail to see any material benefit from its use. 

Cold general baths, the shower-bath, frictions along the spine, etc., 
have been employed ; but the local treatment which has so far been most 
successful, and which promises to supersede all others, consists in the ap- 
plication of ether spray over the spine. About two ounces of ether are 
employed at each sitting, the spray being applied from an atomizer up 
and down the whole length of the spine if the chorea be general. The 
operation, which occupies from ten to fifteen minutes, should be repeated 
daily or every second day. A considerable number of cases have been re- 
ported, in which the spray has apparently had a good effect in control- 
ling the disease. But I repeat my belief, from the large number of cases 
seen in the Bureau for the Relief of the Out- Door Poor, that the arsenical 
and ferruginous treatment will give more satisfaction than any or all other 
measures. 

CHAPTER XV. 

INFANTILE PARALYSIS. 

Paralysis in young children, especially infants, is in most instances due- 
to causes which seldom produce it in adults. The principal cause of it in 
the adult, namely, cerebral apoplexy, is indeed rare in children. Paralysis 
in children has the following recognized causes : 1st. A change in the 
blood, not fully understood, induced by certain grave diseases, as diph- 
theria, typhoid fever, measles, scarlet fever, etc. 2d. Reflex influence. 
The function of some part of the system is in some way disturbed, and 
paralysis occurs in certain muscles, maybe at a distance from the cause, and 
it disappears when that cause is removed, unless it have continued too long.* 
The only rational explanation is found in the fact of a continuous con- 
nection between the local cause and the paralyzed muscles through tho 
afferent and efferent nerves, and the nervous centres. 3d. Compression 
or injury of a nerve-trunk. These cases are rare. Pressing of the portio 
dura by the blades of forceps during birth, described in the next chapter, 
is an example. 4th. An anatomical alteration in the muscular fibres, the 
nerves and nervous centres remaining unaffected. This has been desig- 
nated myogenic paralysis. This form of paralysis is probably often of a 
rheumatic nature. Paralysis of the face or other portions of the surface, 
which sometimes occurs in children and adults from prolonged exposure 
to cold winds, is of this nature. 5th. Some anatomical change in the 
nervous centres, as congestion, haemorrhage, inflammation, emboli, com- 
pression and laceration of brain, whether by tumors, inflammatory pro- 
ducts, or other causes, etc. If there be hemiplegia the presumption is 
that the disease causing it is cerebral ; if paraplegia, that it is spinal. The 



CASE. ±\)9 

following is an interesting example of hemiplegia. The case was related 
by me, and the specimen presented to the New York Pathological Society. 

Maggie, aged 2 years 8 months, was admitted into the Catholic Found- 
ling Asylum about the 1st of September, 1874. She seemed to be in 
good health and was plump and well developed, and her mother stated 
that she had had no serious sickness. After her admission she continued 
well, having the usual appetite, amusing herself through the day, and 
presenting no symptoms to attract attention till December 6th. On the 
evening of December 5th she ate her supper as usual, and was placed in 
her crib, apparently in perfect health. At 3 a.m., the sister who was in 
charge of the ward found her in severe general eclampsia. Imme- 
diately, in addition to the usual local treatment, she administered five 
grains of bromide of potassium, and this was repeated at intervals till six 
or seven doses were administered. Nevertheless, the spasmodic move- 
ments continued, with more or less violence, till l£ p.m., and in the 
muscles of the leg somewhat longer. 

On my arrival at the asylum, at about 6 p.m., I found her lying 
quietly, rather stupid, but easily aroused. Her vision was evidently 
good, and she was conscious ; the pupils responded to light, and the di- 
rection of the eyes was normal ; pulse 104, no cough, and respiration 
natural ; temperature, as ascertained by the thermometer in the axilla, also 
normal. There was no apparent paralysis of the muscles of the face, but 
the right arm and leg were paralyzed, though the paralysis was not com- 
plete. The great toe flexed on tickling the sole of the foot, but the foot 
itself had little or no motion, and on my attempting to flex the leg, which 
was extended, some rigidity of the muscles was observed. At times the 
patient produced slight movement of the thigh upon the trunk. The mus- 
cles of the right upper extremity were more flaccid than those of the leg, 
and below the elbow motion seemed to be totally lost, while a little 
movement remained of the arm on the trunk. I think that during the 
two or three days succeeding the convulsions sensation in the right limbs 
was not entirely lost, though greatly enfeebled. Subsequently paralysis 
in the right limbs, both of the nerves of sensation and motion, was nearly 
or quite total, and continued so till death. Nevertheless, tickling the 
sole of the foot caused some movement of the great toe. On the left side 
sensation and motion were perfect. 

The record of December 9th runs : Has vomiting to-day for the first 
time ; apparently sees well, and appearance of the eyes normal ; has no 
retraction of head, or rigidity of muscles of neck, or along the spine ; 
pulse 96, temperature in the axilla normal ; lies quiet and with eyes shut ; 
is stupid, but not particularly fretful when aroused ; the bowels move 
regularly. 

December 11th, continues to vomit at intervals ; pulse 68. Dec. 
16th, pulse 80, temperature 100° ; vomited once yesterday, none to-day ; 
lies in a constant doze ; takes bromide of potassium gr. iv three times 
daily. Dec. 18th, moans at times, as if in pain ; pulse 180, temperature 
100° ; takes the bromide gr. iv every four hours. 

Dec. 19th, pulse 180, temperature 103° ; there is convergent strabis- 
mus, and the eyes have a wild, almost insane look, but she sees, grasp • 
ing hurriedly a percussion hammer presented toward her ; paralysis of 
nerves of motion and sensation in the right extremities nearly complete ; 
slight movement is still produced in the great toe by titillation ; the vom- 



500 INFANTILE PARALYSIS. 

iting has ceased ; tongue covered with a thick fur ; movements of the 
bowels pretty regular ; has a slight cough, such as is common in cerebral 
disease. 

Dec. 22d, lies quietly on her side in perpetual slumber, with eyes con- 
stantly shut ; pulse 118, temperature 10l£° ; the bowels still move nearly 
normally ; the pupils, exposed to the light, are seen to oscillate, but are 
constantly more dilated than in health ; the urine passes freely ; circum- 
scribed flushing of the features at intervals ; a rash like lichen over abdo- 
men and chest, possibly due to the large quantity of bromide of potassium 
administered. 24th, pulse intermittent ; pupils dilated. 

Dec. 25th, died in profound stupor to-day, having lived nineteen days 
from the commencement of the malady. 

Autopsy. — About thirty hours after death ; weather cool. On remov- 
ing the calvarium and dura mater, which presented no unusual appearance, 
the vessels of the pia mater were found rather more injected than usual, 
but not more so than we sometimes observe in those who die of diseases 
which do not involve the brain. The cerebro-spmal fluid was scanty, and 
the surface of the brain rather dry. The vertex of the left hemisphere 
was unusually prominent, rising perhaps half an inch higher than that on 
the opposite side. At the highest point, which was about one and a half 
inches from the median line, was a circular yellowish spot upon the sur- 
face of the brain about one and a half inches in diameter. Pressure upon 
this spot, made lightly, so as not to produce rupture, communicated the 
sensation of a large cavity underneath filled with liquid, and approaching 
to within two or three lines of the surface. There was no adhesion or 
exudation over this spot ; and the surface of the brain appeared entirely 
normal, except a little cloudiness of the pia mater over a space which 
could be covered by a five-cent piece, a little posterior to the optic com- 
missure. The incised surface of the brain, at a distance from the abscess, 
showed no increase of vascularity. The right hemisphere appeared in 
every way normal, except that its lateral ventricle was filled with pus, but 
not distended. 

On the left side, occupying the centre of the hemisphere, was an ab- 
scess as large as the fist of a child of two years, extending from within 
two or three lines of the vertex, where its site corresponded with the yel- 
low spot on the surface of the brain, to the roof of the lateral ventricle. 
Through this roof the abscess had burst, filling and distending the ven- 
tricle with pus, and thence making its way into the lateral ventricle of 
the opposite hemisphere. The whole amount of pus contained in the 
abscess and the two ventricles was, perhaps, two ounces. The walls of 
the left lateral ventricle were much softened, the upper part of the cor- 
pus striatum and thalamus opticus being nearly diffluent ; the walls of 
the right lateral ventricle were slightly softened, but to less depth. The 
parietes of the abscess, which extended from the roof of the ventricle to 
the vertex, as already stated, were indurated to the depth of one and a 
half lines in consequence of proliferation of the connective tissue, except 
at the base of the abscess, which corresponded with the roof of the ven- 
tricle, where softening had occurred. The spinal cord, so far as it could 
be examined from the cranial cavity, had the usual vascularity, and 
seemed nearly or quite normal. 

The cause of the encephalitis from which the abscess resulted was ob- 
scure. This inflammation, so far as can be ascertained, was idiopathic, 
which is known to be a rare disease. There was no history of otitis, 



SYMPTOMS. 501 

which is one of the most frequent causes of cerebral abscess, nor of heart 
disease, so as to produce embolism. It seems probable, since there was 
no fever till about the fourth day after the convulsions, that an abscess 
had primarily occurred in the hemisphere between the roof of the ventri- 
cle and the vertex, possibly weeks previously. The bursting of this into 
the lateral ventricle, and the constitutional disturbance, inflammation, and 
softening to which this would inevitably give rise afford sufficient explana- 
tion of the history of the case after the commencement of the convulsions. 

Paralysis occurring as a symptom, or sequel of some obvious local or 
general disease, as diphtheria, lesion of the nervous centres, etc., and 
which may occur at any age, need not detain us. It is described in con- 
nection with the primary diseases on which it depends. But there is a 
form of paralysis which in the present state of our knowledge we must 
consider an idiopathic malady, and which is peculiar to the first years of 
life, or is so rare at other periods that it is proper to regard it as strictly 
a malady of infancy and early childhood. It occurs between the ages of 
six months and three years. The following description relates to it : 

Symptoms. — The previous health of the patient is usually good. The 
paralysis does not always commence in the same manner. In a few in- 
stances it begins suddenly in the daytime when the child is apparently in 
perfect health. In some it begins abruptly, after sound sleep. The child 
goes to bed well, sleeps through the night, and awakens in the morning 
paralyzed. I have known it to occur in one instance after sleep in the 
middle of the day. In these cases there has sometimes been an exposure, 
before the sleep, to wind or rain, or from sitting upon a cold stone. In 
other and the majority of cases the paralysis is preceded by a very de- 
cided febrile movement, which comes on suddenly, without appreciable 
cause, and after a few days the power of motion is found to be lost in one 
or more of the limbs. There is no symptom during the febrile movement 
to indicate any affection of the brain : consciousness is retained, and 
there is no more headache or apparent liability to convulsions than occurs 
in other pathological states accompanied by an equal amount of fever. 
Several other modes of commencement have been described by writers, 
but it is not improbable that they have embraced other forms of paralysis 
in their statistics, as, for example, those cases which are hemiplegic or 
which occur in the course of a lingering disease or a hamiorrhagic disease, 
or with cerebral symptoms, as vomiting. Such cases should not in my 
opinion be included in the statistics of infantile paralysis, since their nature 
is uncertain, nor indeed should any cases in which there is doubt as to 
their genuineness. In whatever way the paralysis begins, it is at its maxi- 
mum in the commencement. Occurring as by a stroke, the full extent of 
the paralytic state is exhibited at once, and so far as there is any subse- 
quent change, it is an improvement, as regards the number of muscles 
affected, and the degree of the paralysis. Most frequently the muscles of 
one or both lower extremities are affected. Occasionally one of the upper 



502 INFANTILE PARALYSIS. 

extremities is also paralyzed in addition to the lower, but paralysis of an 
upper extremity is less in degree, and disappears sooner, than that of the 
lower. The bladder and lower bowels remain unaffected, since only the 
muscles of volition are involved. Sensation is unimpaired in the affected 
limbs, and in the commencement there is even in some cases a state of hy- 
peresthesia (West). The febrile movement, which precedes and accom- 
panies the paralysis in certain cases, gradually abates, and in a few days 
nothing abnormal remains except the loss of power in the affected mus- 
cles. These muscles are in a flaccid and relaxed state, so that the limb 
falls by its weight when unsupported, and they are usually free from 
pain. The number of muscles paralyzed varies greatly in different cases. 
Only one muscle or a single group of muscles may be affected, or, on the 
other hand, both the extensor and flexor muscles of two or more limbs. 
In the opinion of Mr. Adams, the following table exhibits the groups of 
muscles and single muscles most frequently involved, and in the order 

stated : 

Groups. 

1. Extensors of toes, and flexors of the foot. 

2. Extensors and supinators of the hand. 

3. Extensors of leg, and with them usually the first group. 

Single Muscles. 

1. Extensor longus digitorum of toes. 

2. Tibialis anticus. 

3. Deltoid. 

4. Sterno-mastoid. 

The following is an example of infantile paralysis, as it not infrequently 
occurs when the result is favorable : A. K., German, female, aged» 3 
years 4 months, fleshy ; had been in the habit of sitting on the ground 
near the house and on the door-sill. On July 2, 187], she had a sound 
sleep in the afternoon, having been entirely well previously, and awoke 
trembling and with a high fever at 3 J p.m. At 8 p.m., the febrile ex- 
citement continuing, general clonic convulsions occurred, lasting about 
ten minutes. At this time I was called to see her, and found her face 
flushed, surface hot, and pulse about one hundred and thirty. Conscious- 
ness returned after the convulsion. Her intelligence was good, tongue 
moist and slightly furred, bowels rather constipated, and the urine freely 
passed. The febrile excitement continued two days, when it gradually 
and entirely abated, but before it ceased paralysis of the left lower ex- 
tremity was observed. No weight at first could be sustained upon this 
limb, and it hung powerless when we endeavored to make her walk. The 
attempt caused her to cry, as if in pain, and pressing upon the thigh, or 
moving it, had the same effect. The thigh of this limb did appear slightly 



PROGNOSIS — PROGRESS. 503 

swollen on inspection, but measurement did not indicate any notable en- 
largement. The difference in circumference was certainly not more 
than one eighth to one fourth of an inch. There was no appreciable in- 
crease of heat in the thigh over the general temperature of the body. 
Sensibility remained in every part of the limb, and the loss of power was 
not complete, for on the first day, as soon as the paralysis was observed, 
slight and imperfect movements could be produced by pinching the limb. 
In three weeks the use of the limb was fully restored, by mildly stimu- 
lating liniments, and simple medicines to regulate the bowels. The ten- 
derness which was observed in this case is only occasionally present. It 
has been attributed to hyperesthesia, but those who hold to the periph- 
eral origin of the paralysis, would probably attribute it to the anatomi- 
cal change occurring in the terminal nerve-fibres. 

Prognosis — Progress. — The paralysis in nearly all cases soon begins 
to abate. The power of motion returns little by little, and whatever im- 
provement occurs is permanent. There is no retrogression in the conva- 
lescence. The sooner improvement commences, the more favorable is the 
prognosis. In the most favorable cases there is complete restoration in 
from three to four weeks. In other patients, while certain of the muscles 
regain the power of motion, other muscles, oftener those of the lower 
extremity than upper, do not recover their function, and, unless proper 
remedial measures be employed, and even with them in certain instances, 
atrophy soon commences. The temperature of the paralyzed limbs falls 
three, five, or even eight degrees, and the amount of blood which circulates 
in it is diminished so that the pulse of the limb is feebler and its vessels 
smaller than in health. With the atrophy the contractility of the muscular 
fibres by the electric current diminishes, and in unfavorable cases after a 
time powerful induced and even primary currents have no appreciable 
effect. The nutrition of a paralyzed limb is always imperfect, and if the 
paralysis occur in a child, its growth is retarded. Therefore in cases of 
protracted or permanent infantile paralysis of one limb a disproportion 
occurs both in diameter and length between it and that on the opposite 
side. If the paralysis continue, the ligaments of the paralyzed limb be- 
come relaxed and lengthened. West mentions a case of paralysis of the 
deltoid in which the humero-scapular ligaments were so extended that the 
humerus dropped from the glenoid cavity, so as to increase the length of 
the limb three fourths of an inch. In the paralysis of certain muscles 
of the lower extremity, and continuance of the contractile power in 
others, we have the conditions which give rise to club-feet, and accord- 
ingly this deformity is the common result of the paralysis when it is not 
cured. 

Etiology. — As infantile paralysis is not a fatal malady, opportunity 
for a post-mortem examination in a recent case seldom occurs. Hence the 
difficulty in determining the exact anatomical change in the nervous sys- 



504 INFANTILE PARALYSIS. 

tern which produces the paralysis. There are now in medical literature- 
records of a considerable number of cases in which autopsies have been 
made, but death occurred so long after the commencement of the paraly- 
sis, usually months or years, that it is difficult to determine whether le- 
sions which have been observed were a cause or consequence. In a ma- 
jority of these autopsies a spinal lesion of some sort was detected, but 
none could be discovered in a few instances, the most important of which, 
were the following : 

Mr. Adams, in his treatise on club-foot, relates a case in which the 
spinal cord, carefully examined, probably only with the naked eye, seemed 
normal. Robin examined the spinal cord microscopically in one case, but 
discovered nothing abnormal, and Elischer made two autopsies in cases of 
this paralysis which had succumbed in variola, but with a negative result 
as regards any lesion in the nervous system (Jahrbuch fur Kinderk., 
1873). The examinations by Robin and Elischer, since they were micro- 
scopic, have been justly regarded as important, and they have been related 
by certain writers in order to sustain the theory that infantile paralysis is 
peripheral, and not centric. But may there not have been a spinal lesion 
which caused the paralysis, and abated, leaving no trace, although its 
effects as regards the muscles continued ? 

Very little was effected, prior to 1863, in determining the cause or 
causes of infantile paralysis by post-mortem examinations, because the 
microscope was so little used, and because in most of the cases reported 
the clinical history or microscopic lesions were such as to show or to ren- 
der it highly probable that the paralysis was not such as is designated and 
understood by the term infantile. Thus Beraud reported a case in which 
tubercles were found in the spinal cord. Hutin, a case in which there 
was atrophy of the lower part of the spinal cord, but the paralysis com- 
menced at the age of seven years. Hammond, a case in which a clot was 
found in the spinal cord ; and Jaccoud, one of spinal arachnitis, with 
thickening of the meninges. Since 1863, seventeen autopsies have been 
recorded in which the spinal cord was carefully examined, and upon these 
we must chiefly rely for our data by which to determine what are the ana- 
tomical changes in the nervous system which probably cause this paralysis.. 
The reader will find these cases tabulated in a lecture by E. C. Seguin, 
M.D., published in the N. Y. Med. Record, January 15th, 1874, and 
the most important of them narrated in a paper on infantile paralysis, 
showing great research, published by Dr. Mary Putnam Jacobi, in the 
N. Y. Obst. Journ. for May, 1874. It is true that all but three of these 
post-mortem examinations were made many years after the occurrence of 
the paralysis ; but in the three cases which were reported by Roger and 
Damaschino, only two, six, and thirteen months had elapsed. The fol- 
lowing were the chief lesions observed in these cases as regards the spinal 
cord : 



ETIOLOGY. 505 



1. Atrophy of motor-cells in anterior cornua, 

2. Nerve-cells, normal, . . . . ■ . 

3. Atrophy (variously recorded) of anterior columns, or cornua 

or part of cord, or roots of anterior nerves, 

4. Sclerosis, 

5. Myelitis, recorded as diffused, central, or slight, . 

6. Central softening (the three most recent cases), . 

7. Small clot in cord (Hammond's case), .... 

8. Sciatic neuritis, ........ 



10 
2 



It is seen that the most common lesions in these cases were those of in- 
flammation of the spinal cord, or such as are known to result from this- 
inflammation, to wit, atrophy of the nervous substances and sclerosis. 

With the data furnished by these post-mortem examinations and the 
clinical histories of cases, we are the better prepared to consider the the- 
ories regarding the etiology of this malady. The views of MM. Roger 
and Damaschino are entitled to great consideration, since the autopsies 
which they made were in cases of shorter duration, and therefore nearer 
the date of the commencement of the paratysis than those which have- 
been reported by other observers. Roger and Damaschino published a 
series of papers on this malady in the Gaz. Med. de Paris in 1871, which 
they conclude with the following propositions : "1. The alteration pe- 
culiar to infantile paralysis is a lesion of the spinal marrow, which causes 
the atrophy of muscles and nerves. 2. The seat of this lesion is the 
anterior part of the gray substance of the medulla, where softened por- 
tions of spinal substance are seen. 3. This softening is of an inflamma- 
tory nature — in fact, a simple myelitis. 4. Infantile paralysis should, 
therefore, be called spinal paralysis of children, and be classed among the 
affections of the spinal marrow, as depending on myelitis." 

To determine the exact character and limitations of the cause of infan- 
tile paralysis is difficult ; but the views of Roger and Damaschino, as ex- 
pressed in the above propositions, seem to harmonize more closely with. 
and to afford a more satisfactory explanation of, the symptoms, histor} T , 
and lesions, thus far observed in ordinary or typical cases, than does any 
other theory. Suddenly occurring, active congestion of the anterior cor- 
nua, many neuropathists regard as the cause of infantile paralysis ; but 
there is that close affinity between active congestion and inflammation 
that they may be regarded as having the same pathological effect in this 
instance, and therefore the two theories of a spinal congestion and spinal 
inflammation may be considered as one. It is not improbable that in some of 
the cases which more speedily recover there is simple congestion ; while in 
the more obstinate cases, and those with inflammatory symptoms, the con- 
gestion has passed into an inflammation, or inflammation w r as present from 
the first. According to this theory, the atrophy so generally observed 
in the twelve cases in which autopsies were made, must be considered a. 



506 INFANTILE PARALYSIS. 

degenerative change resulting from the inflammation or from the paraly- 
sis. That so accurate an observer and so excellent a microscopist as 
Robin could detect nothing abnormal in the case which he examined, was 
probably due to the fact that the inflammation or congestion abated with- 
out producing any degenerative changes in the nervous substance. 

Professor Charcot considers atrophy of the motor cells as the cause of 
the paralysis, but it is much more in consonance with the facts to con- 
sider the cellular atrophy a result than a cause. For how could atrophy, 
which always occurs gradually, and by progressive increase, be the cause 
of a disease which begins abruptly, and is most intense in the very com- 
mencement ? Besides, atrophy does not occur without some antecedent 
disease to cause it. 

In a report to the International Congress at Amsterdam, Drs. Damas- 
chino and Roger give the following summary of the result of their recent 
study of the pathology of infantile paralysis (Le Progres Medical, No. 
39, 1880) : 

1. The anatomical lesions are situated in the motor regions of the 
spinal cord. 

2. They consist of a central myelitis, with a stadium of softening, and 
atrophic destruction of the cells of the gray substance, together with scle- 
rosis of the lateral columns, and considerable atrophy of the anterior roots 
and the nerves leading to the paralyzed muscles. 

3. Atrophy of the cells is not — as Charcot is of opinion — the whole 
process, as it is in progressive muscular atrophy. 

4. The opinion of Leyden, that there is a circumscribed and a diffuse 
myelitis in children, is worthy of consideration. 

5. It remains for future examination to decide whether the myelitis 
begins as interstitial or parenchymatous, in the cellular tissue or the nerve- 
cells. 

It would be a waste of time to consider in full the various theories 
regarding the cause of infantile paralysis. No one at the present time, of 
those who are competent to express an opinion, believes it to be a reflex 
paralysis, and the expression dental paralysis once applied to it is no 
longer heard. There is one theory, however, which should receive more 
than a passing notice, and which was earnestly and -ably advocated by 
Barwell, of London, in lectures published by him in 18*72, in the Lon- 
don Lancet, to wit : " That this paralysis is purely peripheral ; a malady 
affecting the ultimate fibrillse of distribution of the nerves among the 
muscular elements. ... Its essence," says he, " lies probably in 
some subtile derangement in relationship between the ultimate muscular 
and terminal nerve fibres, perhaps from some inflammatory, perhaps from 
some chemical or nutrient change." This theory has much to commend 
it. Those who advocate it believe that the atrophy of the nerves which 
supply the paralyzed limbs and of the motor nerve-cells which connect 



ANATOMICAL CHARACTERS. 507 

with the roots of these nerves in the anterior cornua occurs in consequence 
of the paralysis, just as atrophy of the optic nerve can be traced even 
into the brain when the eye is destroyed. Nor does it dispose of this 
theory to state, as has been stated, that in order that paralysis occur in 
this manner, it is necessary that there should be the action of a poison, 
analogous to the woorari, for we observe something similar to this sup- 
posed peripheral cause in facial paralysis from exposure to cold, in which 
there can be no poisonous influence. This theory therefore rises up most 
strongly in conflict with that which attributes the paralysis to conges- 
tion or inflammation of the anterior cornua, and it is necessary to decide 
between them, or to admit that the paralysis may sometimes have one 
and sometimes the other cause. But the fact that there is in many cases 
of infantile paralysis a decided febrile movement, and much constitu- 
tional disturbance, when there is no evidence of any morbid action going 
forward in the affected limbs sufficient to cause these symptoms, and the 
fact that only one set of nerves is affected, namely, the motor, which have 
a distinct origin in the spine from the sensitive nerves, but are intimately 
associated with them in their distribution, comport best with the theory 
of a central lesion. Therefore, the theory of spinal congestion or inflam- 
mation appears the best established. Nevertheless, all past experience 
shows that medical theorizers are apt to be too exclusive, and that in 
many diseases there is not a simple uniform cause, but that the cause may 
vary, especially when, as in the present instance, the symptoms also vary; 
possibly, therefore, we may yet find that there are cases, especially those 
in which there is little constitutional disturbance and a known exposure 
to cold, in which the cause is peripheral instead of centric. The brain 
and cerebral meninges may be excluded as sustaining any causative rela- 
tion to the paralysis. There is no symptom which indicates that they 
are involved. The mind remains clear, and convulsions are no more fre- 
quent than in any other disease which is attended by an equal degree of 
febrile reaction. 

Anatomical Characters. — All muscular fibres which are in a state of 
disuse, begin in a few weeks to atrophy, and undergo fatty degenera- 
tion. The transverse striae in the primitive muscular fasciculus gradually 
disappear and are replaced by granules of fat, and later still by small oil- 
globules. If we examine with the microscope the fibres from a muscle 
which has been a considerable time paralyzed, but which has still some 
electric contractility, we will find in places the striae remaining, but nu- 
merous opaque granules of a fatty nature within the sarcolemma wherever 
the striae are absent, and in other places, where the degeneration is most 
advanced, oil-globules occur, always small. If the paralysis be more pro- 
found, the striae have all disappeared. At a later stage, usually after 
some years in cases of complete and incurable paralysis, the fatty matter 
may be to a considerable extent absorbed, and the fibrous network of the 



508 INFANTILE PARALYSIS. 

muscle which remains presents a tendinous appearance. There is a great 
difference, however, in different cases, as regards the rapidity with which 
these changes occur. Hammond states that he found the striae remain- 
ing in two cases after the lapse of more than four years of decided par- 
alysis. The nerves of the paralyzed part also undergo atrophy. 

Diagnosis. — This is easy as soon as the attention of the physician is 
directed to the state of the limbs. In a large proportion of cases the 
mother or nurse first observes the paralysis, and calls the attention of the 
physician to it. A knowledge and recollection of the facts in relation to 
infantile paralysis should lead the physician to examine the state of the 
limbs in all cases of marked febrile excitement in young children, occur- 
ring without apparent cause. 

Prognosis. — It may be confidently predicted, if the child be seen early , 
and correctly treated, that the paralysis will diminish, if it cannot be 
entirely cured. If the paralysis have continued a considerable time, and 
there be no electric contractility of the muscles, there is poor prospect of 
any improvement. The induced current will fail, sometimes, to cause 
muscular contraction, when the direct current may produce it ; but if 
there be no response to the direct current, there is no therapeutic agent 
which can restore the use of the limb. 

In cases seen soon after the paralysis commences, and before the stage 
of atrophy, the prognosis is most favorable, when there is still slight vol- 
untary motion, and improvement commences early. In most instances, 
even when the paralysis has been mild, and of comparatively short dura- 
tion, the limb, although its motion be fully restored, is for a long time 
weaker than the limb on the opposite side. 

Treatment. — A physician called at the commencement of the paraly- 
sis should endeavor to remove every cause which might increase the ir- 
ritability of the nervous system. Some advise to scarify the gums,' if 
much swollen and tender from dentition, the bowels should be kept 
regular, worms, if present, expelled by appropriate medicines, and the 
diet be plain and unirritating. As the cause of the paralysis is, in the 
commencement, still operative, measures are appropriate which are cal- 
culated to remove it. 

Local treatment is very important at all periods of the paralysis. In 
the first days cold applications, as by an india-rubber bag containing ice,, 
should be made along the spine. Stimulating embrocations along the 
spine, and upon the paralyzed limb, are appropriate at a later date. Ben- 
efit may also in some instances be derived from the application of dry 
cups along the spine after the cold has been discontinued. Ergot, the 
bromide and iodide of potassium, which may be administered variously 
combined, or singly, are the appropriate remedies for the first twelve or 
fourteen days. Administered every three or four hours in proper dose, 
they are the most effectual of all internal remedies for diminishing spinal 



TREATMENT. 509 

congestion, and preventing effusion, and permanent structural change in 
the cord. 

If the paralysis continue, or if it do not progressively diminish, we 
should not delay more than two weeks from the commencement of the dis- 
ease before employing appropriate measures to restore the use of the 
limbs, and prevent atrophy of the muscles. The expectant plan of treat- 
ment which is proper in many diseases of children is unsuited to this. 
Muscular atrophy may commence in three weeks, and the farther it has 
advanced, the more difficult and tedious will be the cure. Therefore, by 
the close of the second week if the paralysis continue, or be not rapidly 
disappearing, iron as a tonic with strychnia should be prescribed. There 
is probably no better formula for the exhibition of these agents than the 
following from Professor Hammond : 

B. Strych. sulphat., gr. j ; 
Ferri pyropkosphat. , 3 ss ; 
Acidi phosphorici dilut., ~ ss ; 
Syr. zingib., § iijss. Misce. 

One third of a teaspoonful, or one ninetieth of a grain of strychnia, is 
sufficient for a child of two years, administered three times daily. Hil- 
lier, Barwell, and others have employed subcutaneous injections of strych- 
nia, with, it is stated, a good result. While in the first and second weeks 
the child has been allowed to remain quiet, he should now be encouraged 
to use his limbs. Frequent muscular contraction must, if possible, be 
produced, and the voluntary movements, when not totally lost, aid greatly 
in promoting the nutrition of the muscles and restoring their function. 
Immersing the limb for half an hour in water at a temperature of 110 or 
115 degrees, rubbing the limb with a coarse towel, and kneading the 
muscles, aid also in restoring nutrition and tone to them. 

But, fortunately, we have an invaluable agent in the subtle electrical 
fluid, which can be made to penetrate the muscles and cause their con- 
traction when every other measure has failed. The induced current 
should be employed upon the limb every day, or second day, if it cause 
the muscles to act, but if the loss of power be of long standing, or com- 
plete, so that the induced current is not sufficiently powerful, the direct 
current should be used instead. It is not regarded as important which 
way the current passes, provided that the muscles contract. 

In a large proportion of cases a cure cannot be effected until the lapse 
of several months, so that the patience of the physician and friends may 
be put to the test ; but if muscular atrophy can be prevented, and the 
limb kept at nearly the normal temperature, this mode of treatment will 
ordinarily in the end be successful. The primary affection which caused 
the paralysis will, with some exceptions, be removed by the treatment in- 
dicated above, after which the state of the muscles and their nervous 



510 FACIAL PARALYSIS. 

supply demand the whole attention. Observations show that by treat- 
ment perseveringly employed, fatty degeneration of the muscular fibres 
can be not only arrested, but the fat which has already been deposited 
witbin the sarcolemma may be absorbed, and the muscular striae restored. 
In those cases in which it has been necessary to employ the direct current,, 
the induced should be employed, whenever by the improvement of the 
case it is found sufficiently powerful. 



CHAPTER XVI. 

FACIAL PAEALYSIS. 

Causes. — Facial paralysis, in the new-born, commonly occurs from press- 
ure of the blade of the forceps upon the portio dura, at a point external 
to the stylo-mastoid foramen. It may also occur in children of any age, 
as it is known to be in the adult, from exposure of the face to a cold 
wind. The pressure of a tumor upon some part of the portio dura, or 
even of the fist of the child placed under the face during sleep, may cause 
it. It may also result from disease of the temporal bone, producing press- 
ure on the nerve, as caries, periostitis, suppuration, or haemorrhage into 
the aquseductus Fallopii, and also from intracranial disease affecting the 
pons Varolii or the medulla oblongata. 

Symptoms. — The portio dura, which is a nerve of motion, supplies the 
muscles of the face, and therefore its loss of function is at once manifest 
in distortion of the features. The eye of the affected side remains open 
in consequence of paralysis of the orbicularis palpebrarum, the upper lid 
being raised by the levator muscle, which is not paralyzed, as its nerve is 
derived from the third pair. From the inability to wink, the eye be- 
comes irritated by dust and constant exposure, and, in children old 
enough to have an abundant lachrymal secretion, the tears are apt to flow 
over the cheek. On account of the paralyzed and relaxed state of the ' 
facial muscles the mouth is drawn toward the healthy side, while the 
affected side presents a swollen appearance. Movement of the eyebrow 
and of the anterior portion of the scalp on the paralyzed side is also im- 
possible, since the occipito-frontalis and corrugator supercilii are supplied 
by the portio dura. If the cause of the disease be located above the 
origin of the chorda tympani, the flow of saliva, and consequently the 
taste, on the affected side are impaired. If the injury be posterior to the 
gangiiform enlargement, those symptoms are superadded which are due 
to paralysis of the petrosal nerves. 

The accompanying wood-cut represents a case which was under obser- 
vation in the New York Infant Asylum. Its age at admission was about 
five months, and its previous history was unknown. The paralysis was per- 



PARALYSIS WITH PSEUDO-HYPERTROPHY. 511 



If the cause be peripheral,. 
Fig. 21. 



manent. Death occurred some months later from an intercurrent disease^ 
and no cause of the paralysis could be discovered in a careful examina- 
tion. 

Prognosis. — This depends on the cause, 
as from the pressure of the forceps or from 
cold, the prognosis is favorable. In cases 
of deep-seated lesion, unless syphilitic, 
the prognosis is usually unfavorable. A 
syphilitic lesion can often be removed by 
appropriate remedies, and the paralysis 
cured. 

Treatment. — In the paralysis of the 
new-born, from pressure of the forceps, 
all that is required is occasional rubbing or 
gentle kneading over the affected muscles. 
In those who are older, the nature of the 
cause, so far as ascertained, must determine 

the treatment. If there be glandular swellings, and discharge from the 
ear from scrofula, cod-liver oil and the syrup of the iodide of iron are re- 
quired internally, with appropriate external treatment of the glands and 
ear. If syphilis be the cause, mercurials and the iodide of potassium 
should be employed. If the patient do not soon begin to improve, the 
treatment recommended for infantile paralysis, modified somewhat on 
account of the difference in location, is appropriate. Iron and strychnia 
may be administered internally ; friction, kneading, hot applications, and 
the electric current employed. The current should have only moderate 
intensity, for a high degree of it might injure the vision. It should be 
applied every second day, with one pole over the mastoid foramen, and 
the other moved slowly over the muscles. 




Paralysis with Pseudo-Hypertrophy. 



This is a rare disease. It was first described by Duchenne in 1861, and 
since the attention of the profession was directed to it, cases have been 
observed on the Continent, in Great Britain, and in this country. 
Though our acquaintance with this disease is so recent, it has been fully 
and accurately described by various writers in our language. The Trans- 
actions of the London Pathological Society for 1868 contain a translated 
paper relating to it, communicated by M. Duchenne, with photographic 
views, remarks by Lockhart Clarke, and also the histories of two cases 
occurring in London, and exhibited to the Society by Adams and Hillier. 
In this country an elaborate paper has appeared on this form of paralysis,, 
from the pen of Dr. Webber, of Boston, who succeeded in collecting the 
records of forty-one cases (Boston Med. and Surg. Journ., Xov. 17> 



512 PARALYSIS WITH PSEUDO-HYPERTROPHY. 

1870) ; and more recently Dr. Poore, physician to the New York Char- 
ity Hospital, collated the records of eighty-five cases, which furnish the 
material of an excellent monograph published in the New York Medical 
Journal for June, 1875. 

Weakness of the legs, and a peculiar waddling gait, are the first observ- 
able symptoms, and by them we are able to ascertain approximately the 
date of the commencement of the paralysis. In 27 of the cases collated 
by Dr. Poore, the malady began so early in infancy that they were never 
able to walk like other children ; in 5 there is no record in regard to the 
time when the peculiar gait was first observed, or whether they ever could 
walk. Fifty-two, or about two thirds of the cases, walked well at first, 
having no symptoms of the paralysis till after the age of two years. In 
1 5 of these weakness of the legs and the peculiar gait were first observed 
between the ages of two and a half and five years ; in 23 between the 
ages of five and ten years ; in 6 between the ages of ten and sixteen 
years, and in 8 over the age of sixteen years. It is seen, therefore, that 
this malady is pre-eminently one of infancy and childhood. 

The gait, which is unsteady and waddling, has been compared to that 
of a duck. The child stands with the legs wide apart, and from the 
weakness of the legs, and unsteadiness of the gait, frequently stumbles 
and falls. In many cases this muscular weakness and difficulty in walk- 
ing occur before there is any perceptible enlargement of the muscles be- 
yond the normal size. 

The hypertrophy occurs without tenderness, pain, or other nervous 
symptoms, and without fever or constitutional disturbance. Occasionally 
the patient complains of stiffness or aching in the limbs, especially after 
exercise, even before the enlargement is observed, and exceptionally there 
is pain, even acute, in the legs. The hypertrophy is ordinarily observed 
first in the calf of one leg, and then in the opposite calf. In a case 
related by Niemeyer, the muscles of the gluteal region were first affected. 
In nearly all cases the gastrocnemii are hypertrophied. There were only 
two exceptions in the 85 cases collated by Dr. Poore ; but almost any of 
the other muscles, or groups of muscles, may also be involved. The 
muscles which are most conspicuously affected, and which produce the 
characteristic deformities, are those of the extremities and posterior aspect 
of the trunk. Spinal curvature, which is attributed to the weakened state 
of the erector muscles of the spine, appears early, and is seldom absent. 
The bending is such that a plumb-line, falling from the most posterior of 
the spinous processes, falls behind the plane of the sacrum, which is a 
means of distinguishing this disease from certain other spinal affections. 
: The woodcut represents a case which came to the children's class at Belle- 
vue, in April, 1872. The boy w^as two years old, and the mother stated 
that the peculiar gait and the enlargements had only been observed from 
four to six weeks, and yet the curvature of the spine was quite marked. 



ANATOMICAL CHARACTERS. 



513 




He did not return to the class, and his subsequent history is therefore 
unknown. 

Of the muscles in the upper extremities the deltoid and scapular are the 
most frequently enlarged. Hypertrophy of the temporals has been ob- 
served in three cases, of the masseters in two, ^ ftft 

Fig. 22. 
of the tongue in three, and of the heart in four 

(Poore). 

We shall see presently that atrophy occurs 
in the muscular element of the muscles which 
are affected, and that the hypertrophy is due 
to hyperplasia of the connective tissue. Now 
occasionally this hyperplasia does not occur or 
is tardy in occurring, while the atrophy has 
taken place. Therefore, certain muscles may 
have less than the normal volume, which, from 
contrast with those which are hypertrophied, 
increases the deformed appearance. In ordi- 
nary cases the enlargement advances more 
rapidly and continues greater in the gastroc- 
nemii, which are, as we have stated, the muscles 
first affected, than in other muscles, and there- 
fore there is more prominence and hardness of 
the calves of the legs than elsewhere. In advanced cases walking is im- 
possible, and the patient is obliged to remain in a reclining posture. 
Sometimes from the unequal muscular action the feet become extended 
and the toes flexed, so that the child in attempting to walk steps on the 
anterior part of the sole of the foot, as in talipes equinus. 

In the first stages of the disease the electric contractility of the muscles 
is nearly normal, but in advanced cases response to the galvanic current 
becomes more and more feeble, according to the degree of atrophy of the 
muscular fibres. The skin retains its normal sensibility, with exceptional 
instances in which there is numbness either general or in places. Reddish 
or bluish mottling of the surface of the extremities is sometimes observed, 
which is attributed by some to obstructed venous circulation in the hyper- 
trophied muscles, and by others is supposed to be due to the peculiar 
neuropathic state. The bladder and rectum are not involved. The mental 
faculties are more or less blunted and feeble in certain cases, especially in 
those which commence in early infancy, but in some patients they do not 
seem to be materially impaired. 

Anatomical Characters. — There have been so few post-mortem ex- 
aminations of those who died having this disease, that it is still uncertain 
whether there is any centric lesion. Cohnheim examined the spinal cord 
in one case, and could find nothing abnormal. Recently, Mr. Kesteven has 
examined the brain and spinal cord from a case, and found dilatation of 



514 PAKALYSIS WITH PSEUDO-HYPERTROPHY. 

the perivascular canals, both in the brain and spinal cord, and also spots of 
granular degeneration chiefly in the white substance, " caused by loss of 
cerebral tissue replaced by morbid matter." {Jour, of Mental Sci., Jan., 
1871.) As this child was imbecile, it is not improbable that these lesions- 
were connected with the mental state, and not the muscular disease. 

Professor Charcot (Archiv. de Physiol., March, 18*72) reports a careful 
microscopic examination of the spinal cord and of the nerves in a case 
which had continued ten years. He could discover no deviation from the 
healthy state. More recently Dr. J. Loekhart Clarke examined a case 
and found the encephalon healthy, but in the spinal cord there was more 
or less disintegration of the gray substance in each lateral half, and in 
places dilatation of vessels, and commencing sclerosis [Medico- Chir^ 
Trans., 1874). 

It seems, therefore, that central lesions are not essential, and are 
sometimes absent. When they do occur, it is probable that they are 
consecutive to the paralysis. 

The essential lesions in this malady are atrophy of muscular fibres and! 
hyperplasia of the connective tissue which surrounds these fibres. The 
hyperplasia of the one element in the muscle is greater than the atrophy 
of the other, and hence the increase of volume above the normal size. 
The atrophy is probably a primary lesion, for muscular weakness ordi- 
narily occurs for a considerable time before there is any evidence of the 
enlargement, and, as we have seen, certain muscles may undergo the 
atrophy without the hyperplasia. Still the mechanical effect of the 
newly-formed connective tissue, doubtless, increases the atrophy in those 
muscular fibres which this tissue surrounds, and the comparatively quiet 
state of muscles in consequence of paralysis not only tends to promote the 
atrophy and degeneration of these muscles, but also of contiguous 
healthy muscles. 

The muscles which are involved in this paralysis present a pale yellow- 
ish hue, resembling, says Niemeyer, the appearance of lipoma. Examin- 
ing by the microscope, we find in addition to a large increase in the 
fibrous tissue and atrophy, and in some places disappearance of the mus- 
cular element, more or less fatty matter, granular and globular, occupying 
the interstices. Mr. Kesteven describes as follows the appearance of the 
muscles in the case which he examined : " The muscular substance is 
pale, almost white, and very greasy. The superabundance of fat is evi- 
dent to the naked eye. The muscular fibres present the ordinary striation, 
but less distinctly than usual. The ultimate fibres are pale, and separated 
by a large increase of areolar and fibrous tissue." 

Causes. — Why there is this strange perversion of nutrition, so that 
there is an exaggerated development of the intermuscular connective tis- 
sue, and atrophy of the muscular fibres, is unknown. Boys are more apt 
to be affected than girls. Of the eighty-five cases embraced in the statis- 



DISEASES OF SPINAL CORD, ETC. 515 

tics of Dr. Poore, seventy-three were boys, and there was a similar excess 
of males in the cases collated by Dr. Webber. 

There is in a considerable proportion of cases the record of hereditary 
transmission, and in almost all the instances the predisposition is acquired 
from the mother's side. Thus in thirty-seven of Dr. Poore' s cases 
' ' two or more belonged to the same family. ' ' In some instances three 
and even four maternal relatives had this form of paralysis. In one case 
observed by Duchenne, and in a few others subsequently observed, this 
malady seemed to be congenital, for the limbs at birth were unusually 
large, and the patients, when they came under observation, were unable 
to walk. No relation has been observed between this paralysis and syph- 
ilis, scrofula, or other diathesis diseases. 

Prognosis. — This disease is in most instances progressive, terminating" 
fatally after a variable period. It is in its nature chronic, rarely ending 
in less than five or six years. A considerable proportion live longer, 
some even attaining adult age. The paralysis nun be stationary for a 
time, but afterward continue to increase. Duchenne has reported one 
case of recovery. In two or three other instances patients appeared to 
improve somewhat under treatment, but the writers admit they may have 
become worse afterward. Death is apt to occur, not directly from the 
paralysis, but from some intercurrent disease, especially of the lungs. 

Treatment. — The treatment thus far employed has been chiefly local, 
consisting in the use of electricity, and kneading or shampooing over the 
affected muscles. Doth the primary and induced electrical currents have 
been employed, but, unfortunately, without any appreciable benefit in 
most cases. Benedikt, who claims a better result from electrization than 
any other observer, applied the copper pole over the lower cervical gan- 
glion, and the zinc pole along the side of the lumbar vertebra? by means of 
a broad metallic plate. 



CHAP T E R X V 1 I . 

DISEASES OF THE SPINAL CORD AND ITS COVERINGS. 

The diseases of the spinal cord, and of the parts which cover and pro- 
tect it, are important, but they are less understood than are those of any 
other portion of the body. This is partly due to the fact, that in many 
cases the spinal disease coexists with a similar pathological state of the 
brain or its meninges, the symptoms of which predominate and mask 
those which pertain to the spine, partly to the fact that the chief symp- 
toms of spinal disease are often located in organs or parts which are at a 
distance from the spine, and, lastly, to the fact that it is difficult, for 



516 DISEASES OF SPINAL CORD, ETC. 

obvious physical reasons, to determine the exact state of the spine at the 
bedside ; while post-mortem inspection of the spine, which alone can give 
accurate pathological knowledge, is less frequently made than of any 
other organ. 

Certain spinal diseases occurring in childhood are the same as in adult 
life, presenting identical symptoms and lesions in the two periods, and 
therefore they require no extended notice in this treatise. Others are 
common to childhood and maturity, but they present peculiarities in the 
former period which require to be pointed out, while others still are 
peculiar to childhood. 

Spinal irritation is not infrequent in delicate and poorly-fed children. 
I have from time to time observed marked cases of it in the class in the 
Outdoor Department of Bellevue, the patients usually being above the age 
of three or four years, and exhibiting evidences of cachexia. Most of 
them have been spare and pallid, some affected with a nervous cough or 
palpitation, and some with neuralgic pains in the chest, abdomen, or 
elsewhere, which pressure at a certain point upon the spine intensified. 
These cases recover by better feeding, outdoor exercise, mild counter-irri- 
tation along the spine, and the use of tonics, especially of iron. 

Primary inflammation of the cord and its meninges is rare in children. 
Secondary inflammation of these parts is, on the other hand, more com- 
mon in children than in adults. It is common in caries of the vertebrae, 
and in cerebro-spinal fever. The preponderance in functional activity of 
the spinal cord, and the feeble controlling power of the brain, render 
childhood more liable to convulsions and reflex paralysis than any other 
period of life. Until within a recent period, most cases of infantile 
paralysis were believed to be reflex, due to dentition, intestinal irritation, 
etc., but it is now attributed to myelitis in the motor region of the spinal 
cord (see remarks in article, Infantile Paralysis). Still there are cases of 
true reflex paralysis in children, in regard to the etiology of which there 
can be no doubt. Prof. Sayre of this city has called attention to the 
fact, that balanitis and preputial adhesions sometimes cause paraplegia, 
more or less pronounced, in young children, and which is relieved by 
dividing the adhesions, and restoring the mucous surface of the glans and 
prepuce to its normal state. Such a case was brought to the children's 
< lass in the Out-Door Department at Bellevue, in April, 1875. The child 
I'ould not walk, or scarcely stand, without support, but after the division 
of the adhesions, and subsidence of the inflammation, locomotion rapidly 
improved.* It is well known that masturbation sometimes causes a simi- 

* Some months since I requested Drs. Holgate and Bosley, attending physicians 
in the children's class at Bellevue, to make examination of tlie state of the pre- 
puce in infancy. They report that they have found preputial adhesions almost 
daily, in most instances without symptoms, but sometimes with dysuria, and 
only in rare instances with paralysis. 



CONGESTION OF SPINAL CORD, ETC. 517 

lar weakness of the lower extremities. Dr. West relates the case of a 
child " between two and three years old," who began to totter in his 
gait, and finally almost ceased walking. He was observed to practice 
masturbation. " This was put a stop to," and he soon recovered his 
health and his power of locomotion. {Diseases of Children, page 146, 
4th American edition. ) 

Congestion of the Spinal Cord and its Membranes. 

Congestion of the spinal cord and meninges occurs both as a primary 
and secondary malady, the latter being more frequent than the former. 
It may be active or passive. Active congestion, occurring independently 
of meningitis or myelitis, is in most instances transient, and subordinate 
to some graver disease, in the course of which it arises. It is probably 
often overlooked. It is not fatal, and its symptoms are frequently 
masked by those which are referable to the brain or some other organ. 
It is believed to be common in the initial period of certain of the fevers 
of childhood. It is not improbable that the hyperesthesia observed upon 
the thoracic and abdominal surfaces and along the thighs, in the com- 
mencement of remittent and certain other febrile diseases, have their 
origin in a congested state of the spine. To this congestion writers at- 
tribute the lumbar pain and occasional paraplegia in the initial stage of 
variola. Active spinal congestion may also result from the sudden im- 
pression of cold, and to it, as has been stated above, most neuropathists 
attribute the so-called infantile paralysis. 

Certain anatomical circumstances favor the occurrence of passive con- 
gestion of the spinal cord and meninges, to wit, the tortuousness of their 
veins, and the absence of valves in these veins, the lack of muscular sup- 
port of the vessels, and the inferior position of the spine in sickness as 
the patient lies quietly in bed. A common cause of passive congestion 
of these parts is some protracted and enfeebling disease, which dimin- 
ishes the contractile force of the heart (cardiac paresis), producing con- 
gestion of the spinal cord in the same manner as under similar circum- 
stances hypostatic congestion of the lungs occurs. Severe convulsive 
diseases, as tetanus or eclampsia, when protracted or occurring at short 
intervals, commonly produce spinal congestion. In tetanus, this conges- 
tion is extreme, so that extravasation of blood is apt to occur from the 
engorged vessels, especially from those of the pia mater. 

Anatomical Characters. — It is often impossible, at post-mortem ex- 
aminations, to determine how much of the congestion of the spine and 
its meninges is pathological, and how much cadaveric : since, if the 
corpse be placed on its back at death, a very considerable engorgement of 
the spinal vessels occurs from gravitation of blood. If the body have 
been placed on the side or face, this cadaveric congestion is prevented. 
Since, in active congestion, the arterioles and capillaries arc distended 



518 CONGESTION OF SPINAL COKJ), ETC. 

with arterial blood, the color is a brighter red than in passive congestion, 
in which venous blood predominates. Active congestion of the cord 
usually coexists with that of the meninges, but it may occur without it. 
In rases of considerable congestion, the " puncta vasculosa" ap- 
pear upon the incised surface, both of the white and gray substance. If 
the congestion be protracted, or if it recur frequently, it may produce 
permanent dilatation of the arterioles and capillaries, in greater or less 
degree, and it may also lead to sclerosis of the cord. Passive congestion 
seldom, perhaps never, occurs in the cord, without being equally and 
often to a greater extent present in the meninges. Continuing for a time 
it gives rise to transudation of serum into the interspaces over the cord, 
and even softening of the cord may occur to a limited extent from imbi- 
bition of serum. In either form of congestion, extravasations of blood 
are frequent. 

Symptoms. — Spinal congestion is announced by pain in the region of 
the spine, usually in the lumbar, or dorsal and lumbar portions, and irra- 
diations of pain, and tingling in the legs. In addition, more or less 
paralysis of the bladder and legs may result. The paraplegia may occur 
early or not till the lapse of several days. In active congestion, the symp- 
toms are rapidly developed, and they attain their maximum intensity 
sooner than in the passive form. In passive congestion the development 
of symptoms is not only more gradual, but they are ordinarily less pro- 
nounced, and are attended by more fluctuations than in the active form. 
The paralysis, if present, comes on slowly after several days and is in- 
complete. Spinal congestion, especially of the passive form, is apt to be 
associated with cerebral congestion, as for example in tetanus and severe 
eclampsia, and the spinal symptoms therefore coexist with those which 
have a cerebral origin. The duration and the result of a hyperamiic state 
of the spinal cord and its meninges, depend largely on the nature of the 
cause. If it be not relieved within a few days, there is strong probability 
that some other serious pathological state has supervened, as meningitis, 
myelitis, extravasation of blood, or serous transudation, with softening of 
the nervous substance. 

Treatment. — -In the adult, spinal congestion sometimes results from 
the sudden cessation of the hemorrhoidal or catamenial flow, and the ap- 
plication of leeches or wet cups along the spine is indicated. But in the 
child, the abstraction of blood is seldom required. In the acute stage of 
active spinal congestion, with decided febrile movement, cold applications 
along the spine are often beneficial, as by an india-rubber bag. 

In active hyperajmia, laxatives are useful, and rubefacient applications 
should be made along the spine, as by mustard, or by friction with a 
stimulating liniment. In the inflammatory spinal congestion of cerebro- 
spinal fever, I have employed with a very satisfactory result a liniment 
containing equal parts of camphorated oil and turpentine. In both active 



SPINA BIFIDA. 519 

.and passive hyperemia lateral decubitus should be prescribed rather than 
dorsal. The use of ergot, in order to diminish the turgescence of the 
vessels of the spinal cord and meninges, has been advocated by Brown- 
Stiquard, and it is now one of the recognized remedies. Bromide of 
potassium is also a remedy of value, but it is more useful in certain cases 
than in others. It is signally beneficial in those cases in which there is 
also cerebral congestion. When the congestion is increased or produced 
by clonic convulsions, the bromide is the most reliable remedy which we 
possess for the removal of the cause. Thus it should be employed in the 
treatment of the spinal and cerebral congestion in the commencement of 
variola, in which convulsions are so common, and in the convulsions of 
pertussis, which cause extreme passive congestion of the cerebro-spinal 
axis. Passive congestion of the spine, common in exhausting diseases, 
and due to feebleness of the circulation, is best treated by stimulating and 
sustaining remedies, and by the lateral decubitus. It is hypostatic, and 
may be associated with a similar congestion in the posterior part of the 
lungs. 



CHAPTER XVIII. 

SPINA BIFIDA. 

This is one of the most common of the malformations. In its severe 
form it is from its nature incurable, admitting only of palliative treat- 
ment, while in its milder forms, it may be cured, or so relieved as not to 
compromise life. The term spina bifida is applied to a hernia of the spi- 
nal meninges, which produces a rounded tumor, situated posteriorly over 
the spine in the median line. It is due to the congenital absence or in- 
completeness of one or more of the arches of the vertebrae. In excep- 
tional instances, the arch is said to be complete at birth ; but the lateral 
portions separate, and are pressed outward during the first weeks of life. 
The tumor contains the cerebro-spinal fluid, and unless it be small, and 
its walls unusually thick, fluctuation may be detected in it. When the 
child cries the tumor enlarges, and it is reduced by compression, the fluid 
re-entering the spinal canal. If the tumor be large, its complete subsid- 
ence by pressure is apt to produce dangerous cerebral symptoms. Spina 
bifida is the counterpart of hydrocephalus, and the two often coexist. 
If we compress the hydrocephalic head the spinal tumor increases, and 
vice versa. Club-foot is another not infrequent complication. In the 
case which is represented in the accompanying wood-cut, hydrocephalus, 
spina bifida, and club-foot coexisted. The child was brought to the chil- 
dren's class in the Out-Door Department at Bellcvue, and after a few visits 
I lost sight of it. It probably died soon after, since the tumor, over 



520 SPINA BIFIDA. 

which the cuticle was wanting, presented a deep red appearance as if in- 
flamed, so that ulceration and escape of the fluid seemed near at hand. 
There is ordinarily but one spina bifida, the common seat of which is the 
lumbar region, but occasionally there are two or more. If the aperture 

Fig. 23. 




through which the tumor protrudes be small, it is usually pedunculated, 
but if large, it is sessile. In some patients it is covered by skin, which' 
may be normal or somewhat indurated ; in others the skin is absent over 
the entire tumor or its most prominent part, and the dura mater or the 
connective tissue lying directly over the dura mater is exposed, and is lia- 
ble to inflammation from friction. If the walls of the tumor be thin the 
liquid may transude in drops, and they are apt to give way by ulceration 
or rupture. Sudden escape of the liquid, and collapse of the spina 
bifida, involve great danger, for convulsions, coma, and death are the 
probable result. 

The relation of the spinal cord or nerves, or of the cauda equina, to the 
tumor, is a matter of great importance. In many patients the adjacent 
portion of the cord or cauda equina, is deflected through the aperture, and 
lies against the interior of the sac. Spinal nerves also not infrequently lie 
within the sac, some returning into the spinal canal, and others passing 
through the walls of the sac to their points of distribution. Those which 
are deflected into the tumor and return into the canal obviously lie lowest. 
In the most favorable cases, namely, those with a small aperture, or small 
tumor, or a narrow and long peduncle, neither the cord, cauda equina, 
nor nerves lie within the sac. It is important to the practitioner to bear 
in mind that in all probability, unless under the favorable anatomical cir- 
cumstances stated above, the sac contains nervous elements. In rare in- 
stances the liquid, instead of lying externally to the cord, lies within its 
central canal. The substance of the cord then becomes distended, and it 



DIAGNOSIS — PROGNOSIS — TREATMENT. .">!> 1 

incloses the liquid like a delicate sac, just as the hemispheres of the brain 
are unfolded and expanded in the common form of congenital hydro- 
cephalus. As might be expected from the anatomical characters of the 
more serious forms of spina bifida, paralysis, more or less complete, of 
the vesical and rectal muscular fibres, and paraplegia sometimes occur in 
which event the fatal issue is probably not far distant. 

Diagnosis. — This is easy in ordinary cases. The congenital nature of 
the tumor, and the bony edge of the aperture, appreciable to the touch, 
suffice in ordinary cases to establish the diagnosis. The diminution of 
the tumor by pressure, and its enlargement when the child cries, are im- 
portant diagnostic signs. There are various lumbo-sacral tumors located 
in the median line, from which it is important that spina bifida should be- 
diagnosticated. Sometimes a cyst occurs in this situation which was 
originally a spina bifida, but obliteration of the canal in the pedicle 
occurred, just as the canal connecting a hydrocele with the abdominal 
cavity closes. Solid congenital tumors sometimes also occur in the same 
situation, among which, as most common, may be mentioned fatty 
tumors, and tumors containing foetal remains. The most common seat of 
tumors which inclose foetal remains is at the point where spina bifida ordi- 
narily occurs. Physicians have erred in confounding these tumors, as 
well as those which consist of fat, with spina bifida ; but a mistake in 
diagnosis can only occur through haste or carelessness of examination. 

Prognosis. — This is in most instances unfavorable. Ordinarily the 
tumor increases slowly, and finally the sac gives way by ulceration or rup- 
ture ; the liquid escapes, and death occurs in convulsions and coma ; or, 
if the escape of the liquid be prevented by pressure, and the aperture 
closes, a second rupture is probable with a fatal result. In other cases 
the tumor may not rupture, but the cord is softened, or it is injured by 
the abrupt bend, so that paraplegia results, and death after a time occurs 
in a state of emaciation. Rarely the tumor may shrivel away by absorp- 
tion of the liquid, and the disease is cured, or so nearly cured that it 
gives no inconvenience, and the patient lives for years. In other rare in- 
stances the tumor may remain without any material change, and without 
giving rise to symptoms. The spina bifida being small and covered with 
skin, and the aperture leading from it into the spinal canal being also 
small, the patient lives through the natural period of life with little- 
inconvenience. 

Treatment. — It is evident, from what has been stated, that no fixed 
rule can be laid down for the treatment of the spina bifida. In the most 
favorable cases, in which no symptoms occur, and there is no indication 
that the tumor will change or undergo any unfavorable change, surgical 
treatment is not required, except the application of a soft pad to support 
the tumor, to prevent its injury by friction. Indications which justify 
active surgical interference are o-rowth of tumor, absence of skin from it, 



522 SPINA BIFIDA. 

-with tension of the parietes, so that an early rupture is inevitable, and 
dangerous nervous symptoms, as convulsions or paraplegia. 

From the nature of spina bifida it is evident that operations upon it 
must be conducted with caution. The usual presence of the spinal cord 
in the pedicle and in the sac forbid ligation and excision, and render haz- 
ardous attempts to obliterate the sac by producing inflammation within it. 
A safe mode of treatment, but not the most efficient, is to puncture the 
sac and withdraw a portion of the liquid by a grooved needle or hypo- 
dermic syringe. A soft pad should then be applied to produce gentle 
compression. If no unfavorable symptoms occur, the puncture may be 
repeated after a day or two. This operation has been employed with a 
satisfactory result by Sir Astley Cooper among others ; but, simple as it 
is, it is not devoid of danger, for the removal of the liquid, if carried be- 
yond a certain point, may produce dangerous nervous symptoms, espe- 
cially convulsions. In performing the operation, the puncture should 
never be made in the median line, on account of the danger of wounding 
the cord, which lies against the median portion of the sac. The veins 
also, should be avoided. 

Another mode of treatment is by iodine injections. They are prefera- 
ble to other methods, if the neck be long and pedunculated, so as to be 
easily compressed. If the tumor be sessile, and the aperture into the 
spinal canal be free, these injections involve great danger, and are not to 
be recommended ; for more or less of the solution will inevitably enter 
the spinal canal, and give rise to spinal meningitis. Iodine injections 
have been employed with success by Professor Brainard of Chicago, who 
states that he " perfectly and permanently cured" three of seven cases ; 
and by Yelpeau of Paris, by whose method five in ten operations were 
successful, and by many others. Professor Brainard withdrew some of 
the liquid contents, and then injected half an ounce of water containing 
3 \ grains of iodine, and *l\ grains of iodide of potassium. In a few sec- 
onds this w T as allowed to flow out, and the sac was then washed out with 
tepid water. Then a portion of the cerebro-spinal fluid, which had been 
kept warm, was returned into the sac. When he had withdrawn six 
ounces of this fluid he returned two ounces. In employing the iodine, or 
any other irritating injection, it is necessary to compress the pedicle, so 
that the liquid do not enter the spinal canal. Yelpeau employed one 
part of iodine, one of iodide of potassium, and ten of distilled water. 

During a debate in the Societe de Chirurgie, M. Debont recommended 
the evacuation of only a little of the fluid, and the injection of two or 
three drops of the tincture of iodine diluted with an equal quantity of 
water. T. Smith, by the injection of one drop of the tincture, pro- 
duced an amount of inflammation which nearly obliterated the sac (see 
Holmes's Surg. Dis. of Children). Since statistics show so good a result 
of iodine injections, this mode of treatment seems preferable to any other 



VEKTEBRAL CARIES. 523 

for certain cases, and as one drop has produced general inflammation of 
the sac and nearly obliterated it, it seems safest and best to begin with so 
small a quantity. 

If there be reason to believe, from the small size of the orifice and 
other anatomical characters, that neither the cord, cauda equina, nor any 
of the spinal nerves, lie within the sac, it may be thought best to rehiove 
the tumor. It has, indeed, been proposed to open the tumor, immersed 
under warm water sufficiently to observe the relation of the nervous ele- 
ments, and to press them back gently into the canal if they lie within the 
sac. If it be decided to remove the spina bifida, a clamp, or elastic band, 
is placed around the pedicle so snugly as to cause firm adhesion of the 
walls of the pedicle, and excite sufficient inflammation in them to pro- 
duce agglutination, but without causing strangulation or suppuration. 

After a time, perhaps two or three days, when it is evident that agglu- 
tination has occurred from the fact that the liquid cannot be returned 
within the spinal canal by compressing the sac, the tumor may be removed 
by the knife or ecraseur. Statistics do not show so favorable a result of 
this operation as of the iodine treatment, and the reason is obvious, for it 
is only in exceptional cases that the tumor can be removed without injury 
to the nervous tissue, and excision of a portion of the cord, or of impor- 
tant nerves, either produces death or a condition to which death would be 
a relief. 

Spina bifida has also been treated by opening the sac on its side, press- 
ing back the spinal cord or its nerves into the spinal canal, uniting the 
edges of the wound, and then applying pressure to prevent protrusion, bin 
the result has not been favorable. Treatment by simple puncture, f ol 
lowed by compression, and if it fail, as it probably will, the cautious use 
of iodine injections, is the preferable mode of treating ordinary cases of 
spina bifida, which require surgical interference. 



C H A P T E R XIX. 

VERTEBRAL CARIES. 

Vertebral caries, designated also Pott's disease, occurs chiefly in 
♦childhood, but now and then adults are affected with it. It is an osteitis 
of the bodies of one or more vertebrae, ending in their ulceration and a 
lifelong deformity, if not checked. 

Causes. — A reduced state of system, and especially the scrofulous dia- 
thesis, strongly predispose to caries. Hence this malady is more com- 
mon in the city than in the country, where better hygienic conditions 



524 VERTEBRAL CARIES. 

produce a more vigorous constitution. Prolonged anti-hygienic con- 
ditions and protracted ill health from whatever cause predispose to caries. 
In certain cases, there is no apparent exciting cause, while in others there 
is the history of a fall upon or some injury of the spine. 

Vertebral caries may occur in the cervical, dorsal, or lumbar portions 
of the spinal column, but it is more common in the lower dorsal than 
elsewhere. With the development of the osteitis, the body of the verte- 
bra which is affected becomes hyperasmic, and the spongy tissue is soon 
infiltrated with blood and pus. The bone becomes swollen and softened,, 
and, therefore, less resisting than in the healthy state, so that it yields 
under the weight of the shoulders and head, which it sustains. There- 
fore, after the osteitis has continued a certain time, there begins to be 
posterior convexity or rather angularity of the spine, for while the verte- 
bral bodies soften and yield by the weight above them, the arches retain 
their integrity and firmness, and are unyielding. 

Much of the tediousness and suffering of this malady is due to the fact 
that the inflammation is so deep-seated, and a healthy bony barrier is in- 
terposed between it and the surface, so that there is no ready escape of 
the pus. It permeates the spongy tissue, filling the cavities produced by 
the softening and absorption of the bone-substance. If the inflammation 
be of small extent, the amount of pus small, the constitution good, and if 
the disease be early recognized and properly treated, the child may 
recover without any fistulous opening, by absorption of the pus, and with 
little remaining deformity. 

In the large proportion of cases, however, the history is different. The 
disease is not recognized till the stage of deformity, the caries is so exten- 
sive and the pus so abundant, that it escapes between the vertebras, form- 
ing an abscess external to them, which connects with the interior of the 
vertebras by a fistulous canal. This abscess if in the cervical region may 
press upon the pharynx or oesophagus, or upon the air-passages, produc- 
ing dangerous obstruction to the respiration. (See Art. Retro-pharyngeal 
Abscess.) The pus may point and discharge externally near the seat of 
the caries, but in a large proportion of instances it takes a long and cir- 
cuitous route to the surface, or it opens internally. There are instances m 
which it discharges into the pleural or abdominal cavity, or into one of 
the abdominal organs. If, as is sometimes the case, it establishes a con- 
nection with the intestine and escape in the stools, the result will proba- 
bly be favorable. In other instances it descends into the pelvic cavity r 
and finds an outlet by the inguinal ring, or sciatic notch, or it enters the 
sheath of the iliacus or psoas muscle, and points externally. 

When the disease ends favorably, new bone is thrown out around the 
diseased vertebras, preventing any further bending, and giving stability to 
the spine. If the abscess do not discharge, but remain subcutaneous, 
Billroth says : . . . " While the bone disease recovers most fre- 



SYMPTOMS. 525 

quently, a large part, of the pus, whose cells disintegrate into fine mole- 
cules, is absorbed, while the inner walls of the abscess change to a cicatri- 
cial tissue, which in the shape of a fibrous sac contains the puriform fluid. 
Such pus-sacs often remain in this stage for years. " 

If the pus have escaped externally, the abscesses and fistulae contract and 
finally close, their site being occupied by condensed connective tissue. 
The portions of the diseased vertebrae which have retained their vitality 
arc enveloped and supported by the new bone, so that the part of the 
spine which was the seat of the disease, though anchylosed and curved, 
has greater firmness than in health. 

The history of unfavorable cases varies ; the caries may extend. Pus 
finding no vent may accumulate in cavities and sinuses, in which de- 
tached portions of bone float, or it may make its way in such directions, 
that it produces alarming complications, and impairs or obstructs the func- 
tions of important organs. 

Spinal meningitis in the vicinity of the caries, and due to extension of 
the inflammation, is common, and " the spinal medulla," says Billroth, 
" may be endangered by participation in the suppuration, or by being so 
bent by the inclination of the vertebrae, that its function is destroyed." 
Hence the paralysis of the lower extremities, bladder, and rectum, which 
occurs in aggravated cases, and which entails a fatal issue. In a certain 
proportion of cases the blood becomes more and more impoverished from 
the continuance of the inflammation and suppuration, and death occurs in 
a state of exhaustion. In such cases post-mortem examination often dis- 
closes waxy degeneration of important organs, as the spleen, liver, kid- 
neys, and intestines, for it is well known that chronic suppurative inflam- 
mation of the bones is one of the two chief causes of the waxy disease, 
syphilis being the other. 

Symptoms. — Caries of the vertebrae is often preceded by symptoms or 
appearances which are due to the strumous cachexia. Strumous ailments 
have probably occurred in the patient, or in members of the family, or 
without any clear history of struma the child has perhaps for some time 
been in failing health. In cases which I have observed, one of the chief 
symptoms, and sometimes almost the only symptom in the commence- 
ment of the caries, has been neuralgic pain, usually not severe, intermit- 
tent, or more or less constant, at some point in the anterior aspect of the 
body, most frequently in the chest, epigastric, or umbilical region. This 
pain has been present in a larger proportion of cases, than pain in the 
spinal region at the seat of the caries, though Guersant dwells particularly 
upon the latter as a symptom of caries. Patients with this neuralgia are 
not infrequently treated for indigestion, or worms, the true nature of the 
malady not being suspected, and the spine not even being examined* 
This neuralgia seems to be due to compression of the spinal nerves, by 
inflammatory exudation at the points where they emerge from the spinal 



526 V E RTER R A L C ARIES. 

canal. I can recall to mind a number of cases in which I have on differ- 
ent occasions been asked to prescribe for this neuralgia, which was shown 
by the sequel to be undoubtedly the result of vertebral caries, and yet 
with a careful examination of the spinal column could discover no evi- 
dences of disease at any point. After a time, tenderness, pain, and in- 
flammatory induration, appreciable to the touch, may occur in or along 
the spine, but not usually till the malady is well advanced. Lassitude r 
fatigue after slight exertion, poor appetite, with slight fever, are common 
symptoms in the first stage of the caries. 

As the case advances, if the nature of the disease be not recognized, and 
no artificial support of the trunk be provided, the child instinctively seeks- 
some way of supporting the head and shoulders. He rests his head upon 
his hands, or his elbows upon the table. Soon a gibbosity or angularity 
appears, affording clear and positive proof of the nature of the disease. 
Even now there is little or no tenderness when pressure is made directly 
on the spine, but it is observed more w^hen pressure is made laterally upon- 
it. If the inflammation extend so as to involve the meninges and the 
cord, pricking, tingling, numbness or weakness of the legs may occur,, 
which are symptoms of grave import, for it is probable that the case will 
end in paraplegia and death. A state of emaciation and general weak- 
ness, sometimes accompanied by diarrhoea and oedema of the limbs, pre- 
cedes death. But a very considerable degree of curvature is not incom- 
patible with a healthy and normal performance of all the functions, and 
the number who recover, and lived to an advanced age with deformity, is- 
large, as every one knows. 

Diagnosis. — This is often from the nature of the disease obscure and 
uncertain for a time. The long continuance of pain in the chest or 
abdomen, or perhaps in the thighs, without any cause which we can de- 
tect, located at the seat of the pain, should excite suspicion of spinal dis- 
ease. Such pain may be produced by spinal irritation, but in this mal- 
ady pressure on the spine is badly tolerated, and when we touch a cer- 
tain part, the neuralgic pain is intensified. In caries, as we have seen, 
firm pressure upon the spine is tolerated, and it does not increase the 
neuralgia. At a later period in caries there may be spinal pain and ten- 
derness, but there is now also spinal deformity, by which alone the diag- 
nosis is clearly established ; stiffness observed in the movements of the 
spine, pain in the spine, on sudden movement or jarring the body, im- 
paired appetite and general health, and instinctive desire to sit or recline 
in such a way as to relieve the spine partially of the weight of the head 
and shoulders, are symptoms which, if they coexist, afford very strong- 
evidence of the presence of caries, although there be as yet no de- 
formity. 

The spinal deformity of rachitis is distinguished from that of caries, by 
the fact that it occurs slowly without pain or tenderness, and is rounded 



PROGNOSIS — TREATMENT. 52T 

instead of angular. Moreover, the rachitic diathesis precludes scrofulous 
ailments, and the scrofulous diathesis rachitic ailments, as the two diathe- 
ses do not coexist, or but rarely ; so that if there be in the state of the 
patient or have been in his history evidences of scrofula, the presumption 
is that the bending of the spine occurs from caries. In a case of rachitic 
curvature, we find also enlargements of the ankles and wrists, keel-shaped 
thorax, prominent abdomen, rachitic head, etc. 

Prognosis. — The course of this malady, even when the caries is slight 
and the symptoms mild, is tedious. In the most favorable cases the 
general health is but slightly impaired, the caries is confined to one verte- 
bra, and is early diagnosticated and properly treated. On the other hand, 
if the general health be decidedly poor, the child anaemic and wasted, the 
curvature great, and an abscess have occurred, the case is very serious. 
Between these two extremes is every grade. The prognosis is more 
favorable in the child than in the adult. The few adults whom I have 
seen with it all died. It is less favorable in the cervical region than in 
the dorsal or lumbar. A mild case occurring in a good condition of 
health may become grave and even fatal by neglect and improper treat- 
ment. A majority of the patients, if the disease be not too far advanced 
when recognized, recover if properly treated, but the deformity which 
results may prove serious in after-life. The incomplete expansion of the 
lungs in the humpbacked, greatly increases the danger and the dyspnoea 
in bronchitis and pneumonia, and if the caries have been at a low point in 
the spine, and the patient a female, the deformity will probable present 
an obstacle to childbearing. 

Treatment. — The treatment must be constitutional and local, hygienic, 
medicinal, and mechanical. It is of the utmost importance to improve 
the general health, as it is in all chronic inflammations and scrofulous ail- 
ments. Pure air, sunlight, personal cleanliness, and plain but the most 
nutritious diet are required. Tonic and anti-strumous remedies are indi- 
cated. To many patients I have prescribed, three times daily, cod-liver 
oil, to which the syrup of the iodide of iron was added, giving two drops 
to a child of one year, and one additional drop for each additional year. 
The judicious use of alcoholic stimulants will often be found useful, if the 
appetite be poor and general health seriously impaired, as will also the 
vegetable bitters. 

In all strumous inflammations of the bones, which extend to or involve 
joints, and which are in their nature chronic, perfect quiet of the parts, 
so far as it is consistent with the degree of exercise which is required in 
order to improve the appetite and general health, is indispensable for suc- 
cessful treatment of the case. The patient with this malady should be 
encouraged to lie much of the time in bed, for the double purpose of 
preventing movements of the inflamed vertebras, and of relieving them of 
the weight of the shoulders and head. But confinement in bed is badly 



528 VERTEBRAL CARIES. 

tolerated, and exercise is necessary for a healthy functional activity of the 
organs ; therefore mechanical support of the spine is required. The ap- 
paratuses which have been invented for the purpose of supporting the 
spine and rendering it immovable, and of sustaining the head, if the ca- 
ries be in the cervical region, or the head and shoulders, if it be in the 
dorsal or lumbar region, are ingenious and effectual. Some of them are 
rather cumbersome, but others are sufficiently light for the youngest child 
who can walk. The apparatus should be worn for months, care being 
taken to prevent excoriation or undue pressure upon any point. It may 
be removed at night, and reapplied on rising in the morning. 



SECTION II. 

DISEASES OF THE RESPIRATORY SYSTEM 



CHAPTER I. 

CORYZA. 



The term coryza is applied to inflammation of the Schneiderian mem- 
brane. It is acute or chronic. The acute form is primary or secondary. 
Acute primary coryza is common in infancy and childhood. Its usual 
cause is exposure to currents of air, to cold, and especially to sudden 
changes of temperature from warm to cold. The cause is the same as 
that in the ordinary forms of bronchitis. These two diseases frequently 
indeed coexist, occurring from the same exposure. The inflammation in 
such cases commences upon the Schneiderian membrane, immediately 
upon the operation of the cause, and soon after extends to the bronchial 
tubes. Acute coryza may also be produced by the inhalation of irritating 
vapors, hot air, or dust, and also by the presence of a foreign body, as a 
button or bean, in the nostril. 

Secondary coryza is commonly due to a specific cause. The diseases 
in connection with which it occurs are hooping-cough, measles, scarlet 
fever, diphtheria, and constitutional syphilis. In the infant, coryza is 
one of the first manifestations of hereditary syphilitic taint. 

Acute primary coryza ordinarily abates in from one to two weeks. 
The secondary form gradually declines, in most cases, when the primary 
affection on which it depends is cured. Syphilitic coryza is more pro- 
tracted than the primary form, or than that accompanying the eruptive 
fevers. Some children are so liable to coryza that it occurs whenever 
they take cold. Occasionally it is so frequently renewed in the winter 
months that it resembles the chronic form of the disease. 

Chronic coryza is commonly dependent on a dyscrasia, usually the 
syphilitic or strumous. The dyscrasia is often indicated by pallor, flabbi- 
ness of the flesh, and liability to glandular swellings. Certain cases take 
their origin in the nasal catarrh of the exanthematic fevers, the local affec- 
tion continuing after the constitutional disease has declined. Chronic 
34 



530 COHYZA. 

coryza sometimes occurs in children, who appear otherwise in good 
health. It is probable that in such cases there is a dyscrasia of which 
the coryza happens to be the sole manifestation. 

Anatomical Characters. — The alterations which the nasal mucous 
membrane undergoes when inflamed vary considerably in different cases. 
In the simplest and most common form of coryza, this membrane is 
sometimes in patches, sometimes generally reddened, thickened, and soft- 
ened. Its papillae are prominent, producing an inequality of the surface. 
Ulcerations are not common in simple acute coryza, but they sometimes 
occur in the chronic form. 

In diphtheria, and sometimes in scarlet fever and variola of severe type y 
the coryza is pseudo-membranous, and when it presents this form it is 
commonly but not always associated with pseudo-membranous angina or 
laryngitis. A case of pseudo-membranous coryza occurring in measles is 
related by M. Guibert. The patient was a rachitic boy, three and a half 
years old. The pseudo-membrane, in grave cases, may cover almost the 
entire surface of the nostrils, but ordinarily it occurs in patches. 

Symptoms. — The constitutional symptoms are mild or severe, accord- 
ing to the gravity of the inflammation. If the coryza be acute and pretty 
general, there is febrile movement, with thirst and loss of appetite. 
Frontal headache is common, from the proximity of the inflammation to 
the head, or its extension to the frontal sinuses. Sneezing is the first 
symptom in many cases of acute coryza. As the inflamed membrane 
swells, more or less obstruction occurs to respiration. The breathing is 
noisy, especially during sleep, and in severe cases the patient is compelled 
to breathe mostly through the mouth. If there be much obstruction to 
respiration the suffering of the patient is considerable, from the sensation 
of fulness in the nostrils, the headache, and the muscular effort required 
in each respiratory act. 

In the commencement of coryza the patient experiences a sensation of 
dryness in the nostrils, which is soon succeeded by a thin discharge of 
a serous appearance. In the course of a few hours the secretion becomes 
thicker. It is muco-purulent, and remains such till the disease begins to 
decline. Inspissated mucus and crusts are apt to collect within the nos- 
trils and around their orifice in chronic coryza, and sometimes also in the 
acute disease, if the discharge be not abundant. These crusts increase the 
difficulty of breathing. Often the acridity of the discharge is such that 
the skin of the upper lip and around the nostrils is excoriated. 

Prognosis. —Uncomplicated catarrhal coryza rarely terminates fatally. 
It is only dangerous in young nursing infants, in whom it may seriously 
interfere with lactation. Coryza, accompanying the eruptive fevers, 
although it may increase the suffering, does not materially increase the 
danger. Syphilitic coryza subsides when the system is sufficiently 
affected by antisyphilitic remedies. Chronic coryza is sometimes very 



TKEATMENT. 531 

obstinate. It may continue for months or years, giving rise to a con- 
stant, hut often not abundant, discharge. 

Treatment. — Common mild attacks of coryza require little treatment. 
The bowels should be kept open, the feet soaked in mustard-water, and 
the body should be warmly clothed. Inunction of the nostrils is a popu- 
lar remedy, and it seems to give some relief. If coryza commence with 
symptoms which indicate a pretty severe attack, and there are evidences 
of extension of the disease toward the bronchial tubes, an emetic of syrup 
of ipecacuanha, given at an early period, moderates the severity of the 
inflammation and may prevent the occurrence of bronchitis. Afterward 
a simple diaphoretic mixture, as the following, should be given : 

#. Syrupi ipecacuanhse, 3 ij ; 
Spirit aether, nitr. , 3 j ; 
Syrupi siinplicis, 3 ij. Misce. 

One teaspoonful every three hours to a child of six months. In place 
of sweet spirits of nitre, acetate of potassium may be employed in the dose 
of one or two grains for infants ; and if there be decided febrile reaction, 
from half a minim to two minims, according to the age, of tincture of 
digitalis, should be added to each dose. 

A three to five per cent solution of common salt in warm water injected 
into the nostrils with a small syringe, aids materially in removing the 
muco-pus which obstructs the respiration, and in establishing a healthier 
state of the inflamed surface. I have employed in the same way, with ap- 
parent benefit, carbolic acid, glycerine and water, to which the borate of 
sodium or a few grains of chlorate of potassium have been added. This 
may also be conveniently used in the form of spray, with the steam 
atomizer, or thrown up the nostrils with the hand atomizer. The officinal 
lime-water is also a most useful detergent of the nasal surface. 

The treatment proper for pseudo-membranous or diphtheritic coryza is 
detailed in our remarks on the therapeutics of diphtheria. Chronic 
coryza, since it depends upon a dyscrasia, of which it is one of the local 
manifestations, requires remedies appropriate for the blood disease. 
Scrofula needs the syrup of the iodide of iron and cod-liver oil. The 
various ferruginous preparations, as wine of iron, tincture of the chloride 
of iron, iron lozenges, and the vegetable tonics are also more or less use- 
ful. The diet should be nutritious and plain, and out-door exercise, and, 
if possible, country life, should be enjoined. 

If the dyscrasia be syphilitic, similar invigorating measures are re- 
quired, and mild mercurial inunctions to the nasal, surface are especially 
useful. The following, which has been largely employed in the Out-Door 
Department at Bellevue, is one of the best ointments for such cases, and 
its alterative effect renders it also useful for strumous coryza : 

5. Ung. hydrarg. nitratis, ^ij* 
Ung. zinci oxid., ?ij. Misce. 



532 CATARRHAL LARYNGITIS. 

To be thoroughly applied to the Schneiderian membrane by a swab or 
camel' s-hair pencil three or four times daily. Eecently it has been modi- 
fied by the substitution of Squibb 's five per cent oleate of mercury in 
place of the citrine ointment. If the coryza have a distinctly syphilitic 
origin, the application of a two or three per cent oleate of mercury will 
fully meet the indication and be followed by improvement. 

Meigs and Pepper recommend the following ointment in chronic 
coryza, to be applied at night, after the use of injections through the 
day : 

]J. Unguenti hydrargyri nitratis, 3 ss ; 
Extracti belladonnse, gr. x ; 
Axungise, § ss. Misce. 

Astringent injections into the nostrils are not often required in the 
treatment of the various forms of coryza ; but occasionally, if the dis- 
charge be protracted and abundant, weak astringent applications may be 
beneficial, as two to three grains of nitrate of silver, or of alum or tannin, 
to the ounce of water. It should be borne in mind that washes for the 
nasal surface should, as a rule, be employed tepid. 



CHAPTER II. 

CATAEKHAL LARYNGITIS. 

Acute catarrhal laryngitis occurs at all ages, but it is so common in 
infancy and childhood, that it is proper to treat of it in a work relating 
to the diseases of these periods. Like other inflammatory affections of 
the air-passages, it is most common in the cold months, or when the 
weather is changeable. Its usual cause is, therefore, exposure to cold. 
Protracted and violent crying, and the inhalation of acrid vapors are occa- 
sional causes. Catarrhal, or as it is sometimes designated simple laryn- 
gitis, also occurs in connection with certain constitutional diseases, among 
which may be mentioned, measles, scarlatina, and variola. Laryngitis is 
also a common accompaniment of bronchitis, and not infrequently of 
pneumonitis, though its symptoms are apt to be obscured by those of the 
graver disease. It often likewise accompanies pharyngitis, due to exten- 
sion of the inflammation. 

Symptoms. — Catarrhal laryngitis produced by the impression of cold, 
is commonly preceded and accompanied by coryza. The initial symp- 
tom is chilliness, followed by sneezing, and the discharge of thin mucus 
from the nostrils in consequence of irritation of the Schneiderian mem- 
brane. 



SYMPTOMS. 533 

The commencement of laryngitis is indicated by hoarseness, which is 
apparent when the child cries, or, if old enough, when it attempts to 
speak. There is often in severe cases complete loss of voice, so that 
speech above a whisper is impossible. 1 have noticed this most fre- 
quently in the laryngitis which accompanies measles. A cough occurs 
which is at first dry and husky but becomes loose in the course of a few 
days. Expectoration is scanty, unless the inflammation have extended to 
the trachea and bronchial tubes. 

This disease is often accompanied by soreness of the throat, noticed 
in the act of coughing or when the larynx is pressed with the finger. In 
laryngeal catarrh, when uncomplicated, the respiration remains nearly 
natural and the pulse is but little accelerated. In mild cases the nature 
of the disease is often not apparent as long as the child remains quiet, in 
consequence of the absence of symptoms, but the character of the voice, 
when it cries or speaks, or of the cough, reveals at once the nature of the 
affection. 

Acute laryngeal catarrh subsides in from one to two weeks. Occasion- 
ally it lasts three or four weeks before the symptoms entirely disappear. 
Death, which is rare, is due to some complication. 

Chronic laryngitis is much less frequent than the acute form. Its 
anatomical characters are similar to those in other chronic inflammations 
affecting mucous surfaces, namely, thickening and more or less infiltration 
of the mucous membrane, increased proliferation and exfoliation of the 
epithelial cells, and increased functional activity of the muciparous folli- 
cles. 

In the adult, chronic laryngitis is common as one of the lesions of the 
syphilitic or tubercular disease. In the child syphilitic and tubercular 
laryngitis is more rare, but the latter sometimes occurs in connection with 
pulmonary or bronchial tuberculosis. Such patients are emaciated, and have 
the ordinary symptoms of the tubercular disease. Chronic laryngitis also 
occurs in young children, usually infants, as one of the manifestations of the 
strumous diathesis. I have records of several such cases, mostly nursing 
infants. Some of these patients had mild bronchitis, but it was obviously 
subordinate to the laryngitis. Their respiration was noisy and harsh, con- 
tinuing of this character for several weeks and even months. The cough 
was also harsh and loud, conveying the idea of thickening and relaxation 
of the macous membrane covering the vocal cords. Their respiration was 
not notably accelerated, and the blood was apparently fully oxygenated, 
though the friends were often alarmed by the noisy breathing and 
cough. 

In this form of chronic laryngitis there is little expectoration, the fever 
is slight or absent, the appetite remains unimpaired, and the general con- 
dition of the child is good. There are from time to time exacerbations, 
and occasionally improvement is such as to encourage the hope of speedy 



534 CATARRHAL LARYNGITIS. 

cure, but in the cases which I have seen there has not been complete in- 
termission in the disease till the final recovery. Those patients whom I 
have been able to follow through the disease have recovered in from three 
or four months to one year. 

Chronic laryngitis is to be distinguished from frequent attacks of acute 
laryngitis, which are due to fresh exposures, and also from the laryngitis 
which is associated with bronchial phthisis. It is to be distinguished 
from protracted acute laryngitis, which sometimes does not entirely sub- 
side in less than a month or six weeks, by its longer duration, the greater 
thickening of the inflamed membrane, and more noisy respiration. Often 
chronic larnygitis results from the acute disease, the inflammation being 
perpetuated by the struma or dyscrasia of the patients. 

Anatomical Characters. — In acute catarrhal laryngitis the mucous 
membrane of the larynx presents the usual appearance of mucous surfaces 
when inflamed, namely, redness and thickening. It is also somewhat 
softened. Ulcerations rarely, perhaps never, occur in primary acute 
laryngitis. When present in chronic laryngitis, the ulcers are small and 
situated upon or near the vocal cords. Tubercular and syphilitic ulcers 
of the larynx are much more rare in children than in adults. The inflam- 
mation in simple acute laryngitis usually extends over the whole surface 
of the larynx, and also to the upper part of the trachea. It may be pretty 
uniform, or more intense in one place than another, and, like other mu- 
cous inflammations, it is accompanied by more or less rapid proliferation 
and exfoliation of epithelial cells. In most cases of simple laryngitis, 
whether acute or chronic, the inflammation extends to the pharynx, pro- 
ducing redness and thickening, though generally moderate, of the mucous 
membrane which covers it. Examination of the fauces therefore aids in 
diagnosis. 

In the adult oedema glottidis occasionally results from laryngitis. ■ In 
the child there is little danger that this will occur, in consequence of the 
anatomical character of the larynx. In early life there is but little sub- 
mucous connective tissue in the larynx, and therefore less submucous in- 
filtration or effusion during the inflammation. The structural changes 
occurring in catarrhal laryngitis of infancy and childhood relate almost 
exclusively to the mucous membrane. 

Treatment. — Primary and uncomplicated catarrhal laryngitis requires 
little treatment. Most cases would do well by the employment of suit- 
able hygienic measures, without medicines. Benefit is, however, derived 
from the use of demulcent drinks and an occasional laxative. A mixture 
of paregoric and syrup of ipecacuanha, or the mist, glycyr. comp., or a 
small Dover's powder, will relieve the cough. For restlessness, a warm 
foot-bath is also useful. Inhalation of the spray of glycerine and water 
from the atomizer, or of steam, plain or medicated, is also useful. Mildly 
stimulating embrocations, as by camphorated oil with or without a little 



SPASMODIC LARYNGITIS. 535 

turpentine, also aids. It should be rubbed several times daily over the 
throat, or a strip of flannel soaked with it may be applied around the 
neck. Chronic laryngitis dependent on syphilis or tuberculosis requires 
the constitutional treatment which is appropriate for that disease. 
Measures not specific have little effect upon this form of inflammation. 
The chronic laryngitis which I have described as occurring chiefly in in- 
fancy, and which appears to be of a strumous character, is apt to be ob- 
stinate. The patient should be warmly clothed, and constant care should 
be taken that there be no exposure which would endanger taking cold, as 
this would produce an exacerbation of the disease, and tend to counter- 
act what had been gained by remedial measures. This form of chronic 
laryngitis is most satisfactorily treated by the application of tincture of 
iodine upon the neck, directly over the larynx, and the internal use of 
cod-liver oil and the syrup of the iodide of iron. No benefit results in 
this inflammation from expectorant remedies, as squills or senega. 

Spasmodic Laryngitis. 

This is a common disease. It is also called false croup, in contradis- 
tinction to true or pseudo-membranons croup, and, by some of the con- 
tinental writers, stridulous angina or stridulous laryngitis. It should not 
be confounded with spasm of the glottis, which is a form of internal con- 
vulsions, and is not inflammatory. It occurs ordinarily between the ages 
of two and five years. It is commonly a sporadic affection, but Rilliet and 
Barthez state that " it is incontestable that it may prevail epidemically.'" 
They express this opinion, not from their own observations, but chiefly 
from those of Jurine, made in the commencement of the present 
century. 

Causes. — Children in some families are more liable to false croup than 
in others, so that an hereditary tendency to it must be admitted. The 
exciting cause in most cases is exposure to cold. False croup is not un- 
common in the commencement of measles. Narrowness of the rima 
glottidis, and an excitable state of the nervous system, both of which are 
common in early childhood, are predisposing causes. 

Symptoms. — Spasmodic laryngitis is ordinarily preceded for a day or 
two by a slight cough and fever, by symptoms of mild nasal catarrh, 
such as all children are liable to on taking cold. In exceptional cases 
these symptoms are absent and the disease begins abruptly. Singularly, 
it commences in most patients at night, after the first sleep, between ten 
and twelve o'clock. The sleep is usually quiet and natural, but the child 
awakens with a loud, barking cough. There is great dyspnoea, and the 
respiration is harsh or whistling, on account of the narrowing of the chink 
of the glottis from the swelling and tension of the vocal cords. The face 
is flushed and expressive of suffering. The child cries, moves from one 



536 SPASMODIC LARYNGITIS. 

position to another, wishes to be held or carried, seeking in vain for relief. 
The skin is hot, pulse accelerated, the voice hoarse or even whispering. 
After a variable period, usually from half an hour to two or three — not 
more than half an hour with proper treatment — these symptoms abate. 
The patient is then somewhat exhausted and falls asleep. The face is less 
flushed or even pallid, the heat abates, and the pulse is less accelerated. 
The cough, though less frequent, remains for a time barking or sonorous, 
and the respiration, though greatly relieved, is not at once entirely natu- 
ral, but it gradually becomes so. Often there is no return of the spas- 
modic respiration and cough, but sometimes the attack is repeated once 
or more, especially during the subsequent nights. The symptoms vary 
greatly in intensity in different patients. 

As the attack declines, the disease, losing its spasmodic character, be- 
comes a simple inflammation. In some patients there is immediate return 
to perfect health, but oftener the inflammation extends not only into the 
trachea, but also into the larger bronchial tubes, and a tracheo -bronchitis 
remains, which gradually declines. 

The termination is not always so favorable. Spasmodic laryngitis is, in 
exceptional instances, the precursor of other serious affections, which may 
prove fatal. It has been stated that measles often begins with spasmodic 
laryngitis. Bronchitis becoming capillary, may occur in connection with 
it, as may also pneumonia, and by either of these severe inflammations 
the prognosis may be rendered doubtful. There are a few cases on record 
in which it is believed that spasmodic laryngitis was of itself fatal. In 
some of these the dyspnoea was extreme and persistent, and was the 
cause of death. In a case reported by Rogery, on the other hand, the 
respiration became easy before death, and the pulse more and more fre- 
quent and feeble. Death apparently occurred from exhaustion. It is not 
improbable that, had careful post-mortem examinations been made in 
those cases of spasmodic laryngitis which have ended fatally, other le- 
sions would have been discovered besides those located in the larynx, 
perhaps tracheo-bronchitis, with an accumulation of mucus in the larynx, 
producing suffocation, or perhaps in some cases congestion of the brain or 
lungs and serous effusion. 

Anatomical Character — Pathology. — The opportunity does not 
often occur of determining the anatomical characters of spasmodic laryn- 
gitis. I have witnessed but one post-mortem examination. A little girl, 
nine years old, was taken on Friday night with cough and dyspnoea, indi- 
cating a pretty severe attack. The mother, acting through the advice of 
a friend, gave kerosene oil to her in considerable quantity. This was suc- 
ceeded by obstinate vomiting and purging, which continued during Satur- 
day and Sunday, ard terminated fatally on Monday. At the autopsy we 
found uniform and intense injection throughout the whole extent of the 
larynx and trachea and in the bronchial tubes, but there was no pseudo- 



DIAGNOSIS. 537 

membrane on the inflamed surface, and but little mucus and pus. The 
solitary follicles of the intestines and Peyer's patches were tumefied, and 
the gastro-intestinal surface was injected in places. The cause of death 
was obviously the diarrhoea, apparently of an inflammatory character, and 
probably produced by the kerosene oil." The condition of the mucous 
membrane of the larynx was that which is ordinarily present in spasmodic 
laryngitis, though in some cases in which post-mortem examinations have 
been made the evidences of laryngeal inflammation were slight. Guersant 
relates a case in which the surface of the larynx seemed to be nearly in its 
normal state. Death in cases of slight laryngitis is due to causes which 
are independent of the larynx. In Guersant's case tuberculosis was 
present. 

There is, as has already been intimated, another and an important ele- 
ment besides the inflammation in the pathology of spasmodic laryngitis — 
an element producing those phenomena which render it a disease distinct 
from simple laryngitis. I refer to spasm of the laryngeal muscles. This 
element pertains to the nervous system, so that spasmodic laryngitis is 
allied both to the neuroses and to the inflammations. 

Diagnosis. — The disease for which spasmodic laryngitis is most fre- 
quently mistaken is pseudo-membranous croup. The friends, indeed, 
usually make this mistake in forming their opinion of the case before the 
physician arrives ; and there can be no doubt that many of the cases 
which physicians have published in medical journals as true croup were ex- 
amples of this affection. The points of differential diagnosis are the fol- 
lowing : True croup begins with symptoms which at first are slight, so as 
scarcely to arrest attention, but which gradually increase in intensity. The 
cough becomes more harsh, and the respiration more difficult, by de- 
grees. This increase in the gravity of the symptoms occurs by day as 
well as by night. On the other hand, false croup, though preceded by 
symptoms of nasal catarrh, commences abruptly. The symptoms have 
from the first their maximum intensity, and the time at which it com- 
mences is the night. Again, the cough in spasmodic laryngitis possesses 
aloud, sonorous character ; while in true croup it is harsh or rough, from 
the presence of the membrane, and having, therefore, less fulness. The 
voice in spasmodic laryngitis may be hoarse, but it is not lost, or is lost 
only for a short time. It afterward becomes natural, or is slightly 
hoarse. On the other hand, in true croup, the voice, from being natural 
at first, is gradually extinguished. In fatal cases it soon becomes whis- 
pering, and continues such till the close of life ; in those that recover, 
the voice remains hoarse for several days. These differences are important, 
and, if fully appreciated, are in most instances sufficient to establish the 
diagnosis. Besides, in a large proportion of cases of true croup, portions 
of the pseudo-membrane may be discovered on inspecting the fauces, and 
the faucial surface is deeply injected, while in spasmodic laryngitis there 



538 SPASMODIC LAKYNGITIS. 

is, with rare exceptions, no false membrane upon the surface of the fau- 
ces, and but a moderate amount of congestion. 

Laryngismus stridulus, or internal convulsions, must not be con- 
founded with this disease. It is not inflammatory, but purely spasmodic, 
suddenly commencing and abating — identical, it is believed, in character 
with tonic convulsions of the external muscles, but affecting the internal 
muscles of respiration. This disease has already been fully described. 

Prognosis. — Little need be added, as regards the prognosis, to what 
has already been stated. While a favorable opinion in reference to the 
result may ordinarily be expressed, the physician should not forget the 
fact that death may occur. Symptoms indicating an unfavorable termi- 
nation are : great and continued dyspnoea, not diminished by the proper 
remedial measures ; stridulous expiration as well as inspiration ; lividity 
of the prolabia and fingers ; pallor and coldness of surface ; pulse pro- 
gressively more frequent and feeble. Convulsions and coma may also 
occur near the close of life. 

Treatment. — The indications of treatment are twofold : first, to relieve 
the spasmodic action of the laryngeal muscles ; secondly, to cure the 
laryngitis. To meet the first indication, a warm bath of the temperature of 
about 100° should be employed as soon as possible after the commence- 
ment of the attack. The patient should be kept in it ten or fifteen min- 
utes, in order to obtain its full relaxing effect. In mild cases a warm foot- 
bath may be sufficient. A second means is the use of an emetic, which 
should be simultaneous with the bath. To children under the age of 
three years, syrup of ipecacuanha should be given, in doses of one tea- 
spoonful, repeated in twenty minutes, till vomiting occurs ; or alum and 
syrup of ipecacuanha, two drachms of the former to one ounce of the lat- 
ter, may be given in the same dose. The alum and the syrup produce 
more prompt emesis than the syrup alone. Children over the age of 
three years, unless of feeble constitutions, are best treated by the com- 
pound syrup of squills in teaspoonful doses, or a mixture of this with 
syrup of ipecacuanha. It is not often necessary to give more than three 
or four doses, and sometimes one or two are sufficient to produce vomit- 
ing. 

In most cases, by the use of the warm bath and the emetic, the symp- 
toms are rendered milder, and convalescence soon commences. 

In the American Journal of the Medical Sciences, April, 1867, Dr. R. 
E. Livingstone reports a case of laryngitis treated by Squibb's ether. It 
is stated that portions of pseudo-membrane, from one-eighth to three- 
fourths of an inch in length, were expectorated ; but the symptoms cer- 
tainly indicated a spasmodic element as decided as in spasmodic croup, 
and the benefit from the ether was apparently due to the relaxation of the 
laryngeal muscles which it produced. The treatment of the patient, who 
was two years old, was commenced by the administration by the mouth 



TREATMENT. 539 

of half a teaspoonful of the ether, and followed by its inhalation. " In 
precisely eight minutes from the time the patient commenced the inhala- 
tion, the abnormal muscular exertion ceased ; a general relaxation took 
place ; the pulse (which had numbered 150) fell to 100." Ether, judi- 
ciously employed, will probably prove to be a useful remedial agent in 
spasmodic forms of laryngitis, whether or not it have any effect on pseudo 
membranous formations. A large majority of cases, however, recover 
speedily without its employment, or by the other measures recommended. 

Attention should always be given to the state of the bowels in spas- 
modic laryngitis. If they are not well open, a purgative should be admin- 
istered. For those that are robust, and with considerable febrile move- 
ment, the saline cathartics are ordinarily preferable, as Rochelle salts, or 
a purgative dose of calomel may be administered. The cathartic should 
not be prescribed till the nausea from the emetic has subsided. By its 
derivative effect, it tends to diminish the laryngitis, and, in severe cases, 
it may obviate the need of depletion by leeches. 

Inhalation of the vapor of hot water, and the application of a sinapism 
over the neck and upper part of the sternum, followed by an emollient 
poultice, are useful adjuvants to the treatment. 

The most convenient and effectual way of employing vapor is, how- 
ever, by the atomizer, and as the chief danger is that the inflammation 
may become pseudo-membranous, I am in the habit of using in the atom- 
izer the officinal lime-water. 

When the spasmodic element in the disease is relieved, the case be- 
comes one of simple laryngitis, and the general plan of treatment recom- 
mended for that malady is proper for this. Small doses of ipecacuanha, 
or of one of the antimonial preparations, as the compound syrup of squills, 
not sufficient to cause nausea, should now be given at regular intervals. I 
have sometimes added to the expectorant one drop of the tincture of 
aconite root for robust children, over the age of three or four years, 
having a full and rapid pulse, flushed face, and other evidences of active 
febrile movement. Its effect should be watched, and it should be dis- 
continued w r hen its sedative influence on the circulation begins to be ap- 
parent. It should not be given in the spasmodic laryngitis which occurs 
in the commencement of measles. 

If, however, the disease do not speedily terminate by recovery of the 
patient, or, more rarely, by death, there is nearly always tracheobronchi- 
tis, or a more serious affection, coexisting with the laryngitis, or following 
it, so that depressing measures should not be long continued. Ex- 
pectorants of a stimulating character, as carbonate of ammonium, or syrup 
of senega, are required in the course of a few days, and in young and 
feeble children they should be given at an early period. 

The mode of treatment recommended above is appropriate for that 
large class in whom the inflammatory element predominates. In a smaller 



540 PSEUDO-MEMBRANOUS L A R Y JS G I T I S . 

number of cases the nervous element predominates over the inflammatory, 
and the treatment should be in some respects different. Such children 
are usually pallid and of spare habit, having, indeed, the nervous tempera- 
ment. They are liable to attacks of this disease, though generally of a 
mild form, on slight exposure to cold, and with a very moderate amount 
of inflammation. The treatment in these cases should be directed more 
to the nervous system. My plan has been, in the treatment of such pa- 
tients, after perhaps the use of a mild emetic, to give quinine, one grain 
three or four times daily, to a child from three to five years old, prescrib- 
ing at the same time a simple expectorant, as syrup of squills, and a mildly 
irritating application to the throat. The symptoms in these cases are not 
severe, and active measures are not required, though the peculiar cough 
continues longer than in the more inflammatory forms of the malady. 

The patient with spasmodic laryngitis should be kept in a warm room 
during the paroxysms, and should inhale an atmosphere loaded with 
moisture. 

Trousseau recommends a mode of treatment of spasmodic laryngitis 
which was first suggested by Graves, of Dublin. It consists in the appli- 
cation underneath the chin, so as to cover the larynx, of a sponge soaked 
in water as hot as can be borne ; in ten or fifteen minutes it is repeated. 
This reddens the skin, producing revulsion from the larynx. The hoarse- 
ness, dyspnoea, and cough diminish with this treatment, and some recover 
without other measures. 

Guersant and others speak of the importance of prophylactic manage- 
ment of children who are liable to this disease. Attention should be given 
to the dress, so that there may be sufficient protection from atmosphe- 
ric changes, and there should be an equable temperature of the apartments 
in which they reside. Children of a decidedly nervous temperament, in 
whom the slightest laryngitis is apt to be spasmodic, require additional 
prophylactic measures. They are pallid, and in a more or less cachectic 
state. Such children are benefited by chalybeate and vegetable tonics, 
and by exercise in suitable weather in the open air. 



CHAPTER III. 

PSEUDO-MEMBRANOUS LARYNGITIS. 

The term pseudo-membranous laryngitis, or true croup, is applied to a 
common and fatal disease, the essential anatomical character of which is 
inflammation of the mucous membrane of the larynx, with the formation 
upon its surface of a pseudo-membrane. It occurs most frequently be- 



ANATOMICAL CHARACTERS. 541 

tween the ages of two and seven years. It is rare in adult life, and also 
under the age of six months. 

Causes. — There is greater liability to this disease in some children 
than in others, and occasionally the predisposition to it appears to be in- 
herited. The common exciting cause is exposure to cold. Those chil- 
dren, especially, are liable to croup, who live in heated apartments, and 
are taken into the open air without proper covering, and those who a part 
of the time are warmly and a part of the time thinly clothed, especially 
as regards the covering of the neck. This disease is common among the 
poor of New York, who live in close rooms, overheated through the day 
and cool at night. Another less common cause is the inhalation of irri- 
tating vapors, or swallowing irritating or corrosive liquids. I have known 
a child to die from swallowing acetic acid, and another from scalding 
water, both having the dyspnoea and cough of true croup. 

This disease is ordinarily primary, but occasionally it is secondary. 
The secondary form may occur in the declining period of measles. Croup 
is most common in the winter months, and in times of changeable weather. 
It is said, also, that it sometimes occurs as an epidemic, but the supposed 
epidemics were no doubt diphtheritic. 

Anatomical Characters. — The inflammatory action in this malady 
affects not only the mucous membrane, but, in a certain proportion of 
cases, extends to the submucous connective tissue, causing infiltration or 
oedema. The mucous membrane itself undergoes similar alteration to that 
in simple or spasmodic laryngitis, consisting of hyperaemia and thicken- 
ing, proliferation, and rapid desquamation of its epithelial cells, and an 
abundant production of muco-pus. Sometimes the redness is found only 
in patches at the autopsy ; in other cases it extends over the whole sur- 
face of the larynx. Exceptionally the redness has disappeared, so that 
the laryngeal mucous membrane, though thickened and softened, presents 
nearly its normal color. In all except the mildest cases the inflammation 
extends further than the larynx, involving not only the surface of the 
pharynx, but also in greater or less degree that of the trachea and bron- 
chial tubes. 

The distinguishing feature as regards the anatomical character of this 
disease remains to be noticed, namely, the false membrane, which covers 
the laryngeal and often contiguous surfaces. It has long been supposed 
that this consists of fibrin, which, exuding in its liquid state from the 
submucous vessels, becomes fibrillated when exposed to the air, its inter- 
stices being filled with a greater or less amount of pus, epithelial cells, 
and amorphous matter. At a recent date Wagner surprised pathologists 
by the statements that these pseudo-membranes contain no fibrin, but that 
they consist of epithelial cells, which, undergoing some form of degen- 
eration as they are pushed forward from the mucous surface, enlarge so 
as to appear under the microscope as irregular blocks interlacing with each 



542 PSEUDO-MEMBRANOUS LARYNGITIS. 

other. By employing the picro-carminate of ammonium, or a weak am- 
moniacal solution of carmine, Weber and other microscopists have been 
able to trace. the boundaries of these irregular and interlacing blocks, 
which have: prolongations like the shape of a stag's horns, and they have 
observed the intermediate forms of transition between these and the nor- 
mal epithelial cells. 

But other and more recent authorities in pathological histology have 
demonstrated the presence of fibrin in the pseudo-membrane, in addition 
to the enlarged and degenerated epithelial cells of which it is chiefly com- 
posed. Rindfleisch says : " The pseudo-membrane is of a peculiarly 
stratified structure, since upon a layer of cells at tolerably equal dis- 
tances there always follows a layer of fibrin, and this sequence is re- 
peated from one to ten times, according to the thickness of the mem- 
brane." {Pathol. Histol., translated, page 351.) As lending support to 
the views that the pseudo-membrane does contain fibrin, the fact may be 
stated, that while in the ordinary pneumonia of young children there is 
no fibrinous exudation in the air-cells, this exudation does occur, at least 
in a certain proportion of cases, in pneumonia occurring as a complica- 
tion of croup. Thus, recently, in this city, in a pneumonic lung, from a 
case of fatal croup, occurring at the age of about two years, Prof. Francis 
Delafield found fibrin in the exudation of the air-cells. The exact nature 
of the degeneration which the epithelial cells undergo is unknown. Their 
appearance is so altered by protoplasmic change and infiltration, that they 
can be recognized as altered epithelial cells only by chemical tests. MM. 
Cornil and Ranvier state : " We have verified the correctness of the 
description given by Wagner ; we have separated and colored the cells by 
means of the picro-carminate of ammonium, and, in consequence of the 
facility which they present of fixing the carmine, we conclude that they 
are not filled with fibrin, but rather by a matter resembling mucin. 
These exudats of true croup are pressed forward and detached in propor- 
tion as the globules of pus or new epithelial cells are produced underneath 
them." 

In Virchow's Archiv., Band, lxx., 1877, Dr. Carl Weigert relates .very 
interesting experiments in which he produced pseudo-membranous croup 
upon the laryngo-trachial surface of the rabbit, by applying to. it a weak 
ammoniacal solution. After two days the animal was killed, and the exuda- 
tion was carefully examined. The mucous membrane underneath the exu- 
dation was found hypersemic, and denuded of epithelium. Weigert, in- 
deed, concluded from his observations, that the croupous membrane does 
not form, unless the epithelial layer be first destroyed, a point in reference 
to which some of the New York microscopists would take issue. The 
relation of the pseudo-membrane to the mucous surface was simply that of 
contact. The microscopic examination of the adventitious layer was in- 
teresting. Its lowest part contained ill-defined (informes) elements, some 



ANATOMICAL CHARACTERS. 543 

of which preserved a resemblance to the epithelial cells. By the addi- 
tion of strong acetic acid, these elements swelled, took the form of epi- 
thelial cells and exhibited nuclei. Free nuclei were found, in the interspaces, 
resembling . more pus-cells or white blood corpuscles than the nuclei of 
epithelial cells. Therefore Dr., Weigert concludes that the undermost 
part of the croupous layer consists mainly of epithelial debris. Secondly, 
immediately above this he found a different layer consisting of a network 
of delicate fibres in the meshes of which were free nuclei. This net- 
work evidently consisted of fibrin, as it gave the reactions of this sub- 
stance. Thirdly, penetrating the upper part of the fibrinous network and 
overlying it was a layer of mucus containing large cells with large nuclei, 
and grains of black pigment. From all these examinations which have 
been made by competent microscopists, we must conclude that the croup- 
ous exudation consists largely of altered epithelial cells, and that it also 
contains a network of fibrin. 

The pseudo-membrane varies greatly in amount in different cases. It 
may occur only in points or small patches, which are generally found in 
the vicinity of the vocal cords, while in other cases it extends an almost 
continuous membrane from the epiglottis into the bronchial tubes, and 
there is every grade between these two extremes. It fills the orifices of 
the muciparous follicles, and the minute depressions upon the mucous 
surface, being closely adherent, so as not to be detached by efforts of 
coughing or vomiting, except in small portions. 

As the inflammation commonly extends beyond the larynx, so the 
pseudo-membrane, in a large proportion of cases, is formed not only upon 
the laryngeal, but also upon contiguous surfaces. In thirty-three cases of 
true croup, comprised in the statistics of Dr. Ware, of Boston, pseudo-mem- 
branous pharyngitis was also present in all but one ; and in nineteen cases 
observed by Dr. Meigs, of Philadelphia, in all but three. The formation 
of a pseudo-membrane in the trachea in connection with that in the larynx 
is also common, and is not infrequent in the bronchial tubes. M. Guersant 
has, so far as I am aware, collected the largest number of records relating 
to the extent of the pseudo-membrane in true croup. In an aggregate of 
120 cases it was confined to the larynx and trachea m 78, or about two- 
thirds, while in the remainder, namely 42, it extended into the bronchial 
tubes. 

In those whose systems are robust, the false membrane is usually firmer 
than in those whose systems are reducedo In a state of decided cachexia 
it is sometimes friable and easily detached. If the case continue from 
four to six days, it begins to soften from commencing decomposition, the 
minute fibres which attach it to the mucous membrane give way, and, in 
favorable cases, by the effort of coughing or vomiting, it is thrown off. 
Separation is aided by muco-pus, which collects underneath. In fatal 
cases the false membrane, if detached by the efforts of the child, may be 



544 PSEUDO-MEMBRANOUS LARYNGITIS. 

reproduced, so that in twelve to eighteen hours the dyspnoea returns. 
Pneumonia not infrequently complicates croup. In extreme cases, in 
which inspiration is difficult in consequence of the obstruction, the lungs 
are only partially inflated, and imperfect decarbonization of the blood 
and sometimes collapse of certain pulmonary lobules are the result. Oc- 
casionally there is that degree of thickening of the mucous membrane, 
and submucous infiltration, that the dyspnoea and danger occur more from 
these than from the presence of the pseudo-membrane. 

In the New York Foundling Asylum, in two patients death oc- 
curred with all the phenomena of pseudo-membranous laryngitis, and 
the obstruction was found to be due entirely to the thickening and infil- 
tration of the mucous and sub-mucous tissues largely by newly-formed 
corpuscular elements. 

Symptoms. — In some cases, pseudo-membranous, like catarrhal laryn- 
gitis, is preceded by coryza and pharyngitis, while in others laryngitis is 
present from the first. The commencement of croup is indicated not 
only by fever, diminished appetite, thirst, and such symptoms as accom- 
pany all acute inflammations, but by certain other symptoms which enable 
us to diagnosticate this from all other diseases, except diphtheritic croup. 
The cough is one of the earliest symptoms which distinguish true 
eroup from other laryngeal inflammations. It is hoarse or harsh ; its char- 
acter may be expressed by the term dry or suppressed. It differs from 
the cough of spasmodic laryngitis, which is less hoarse and more sonor- 
ous. It is much more frequent in some cases than in others ; in many 
patients, toward the close of life, it nearly or quite ceases. Hoarseness of 
the voice is also one of the first and most constant symptoms, and it con- 
tinues throughout. Toward the close of life the voice is usually lost, and 
the child expresses its thoughts in an indistinct whisper. 

The amount of expectoration varies considerably in different patients 
according to the presence or absence of bronchial inflammation. If the 
inflammation extend no lower than the upper part of the trachea, the 
sputum is scanty during the whole course of the disease. In ordinary 
cases it is scanty at first, then more abundant, and again more scanty if 
the case be fatal. The scantiness of the sputum toward the close of life is 
due not entirely to exhaustion of the patient, but in part to obstruction 
in the larynx above the mucus and pus. By vomiting a much larger 
quantity is expectorated than by the cough. Frequently small portions 
of pseudo-membrane are expectorated with the mucus and pus, and oc- 
casionally also larger masses, complete moulds, indeed, of the larynx, 
trachea, or even of the bronchial tubes. 

The respiration is accelerated, but not so much as in pneumonia or 
capillary bronchitis. In the advanced stage it commonly becomes slower 
than at first. As the obstruction in the larynx increases, the respiration 
assumes more and more the character which has been designated abdomi- 



SYMPTOMS. 545 

nal ; the infra-mainuiary region is depressed in each inspiratory act, while 
the larynx approaches the sternum, and the alse nasi are dilated. Patients 
sometimes have painful attacks of dyspnoea, due to detachment of an 
edge of the pseudo-membrane, and its doubling upon itself. In the par- 
oxysm, the sufferer throws himself from side to side in the bed, or reaches 
his arms to his mother or nurse for relief ; his eyes are wild, features anx- 
ious, and, in severe paroxysms, fingers and prolabia livid. In the interval 
there is comparative quietude, though the respiration is constantly em- 
barrassed. 

The frequency of the pulse varies according to the extent of the inflam- 
mation and the stage of the disease. In the commencement of primary 
croup it ordinarily ranges from about one hundred and ten to one hun- 
dred and twenty beats per minute. In the course of the disease it be- 
comes more frequent, and toward the close of life feeble. 

Now and then a patient presents a remission in symptoms due to ex- 
pectoration of membranous shreds and muco-pus, and the friends may 
think that the danger is passed. Unfortunately the lull in symptoms is 
in most cases deceitful, as the cause of the dyspnoea is rapidly reproduced. 
I once attended a case in which there had been such dyspnoea that an un- 
favorable prognosis was given. An almost complete intermission, how- 
ever, occurred in the symptoms, with the exception of the febrile move- 
ment, so that a physician who visited the patient at this time diagnosti- 
cated an essential fever. Within a few hours, the obstruction being re- 
produced, the symptoms returned with greater violence than ever, and 
the child died. So complete an intermission seldom occurs in a fatal 
case ; and in most patients, during the time of temporary improvement, 
there is still such dyspnoea, with the characteristic cough, that the nature 
of the disease is apparent. 

If the stethoscope be applied over the larynx in true croup, the loud ex- 
piratory as well as inspiratory sound is heard as the air passes by the ob- 
struction. This sound is often transmitted to every part of the chest, so 
as to obscure the rales which may be produced there. Auscultation over 
the chest reveals either the vesicular niurmur, perhaps somewhat dimin- 
ished in intensity, or more frequently the sonorous and afterward moist 
rales due to coexisting bronchitis. In a limited number of cases, dulness 
on percussion is observed at some part of the chest, with bronchial respi- 
ration, indicating pneumonia. Recovery from croup is in most patients 
gradual ; the voice becomes less hoarse, the cough looser, and the dyspnoea 
ceases by degrees. The structural changes which have occurred in the 
mucous membrane of the larynx do not disappear till several days after 
the last pseudo-membrane is detached. 

Fatal cases may terminate in two or three days, but their ordinary 
duration is from five to fourteen days. Death may result directly from 
the thickness and firmness of the pseudo-membrane, which obstructs the 
35 



546 PSEUDO-MEMBRANOUS LARYNGITIS. 

entrance of air. Sudden death in a paroxysm of dyspnoea may occur 
from the detachment of one end of the pseudo-membrane, and its folding 
upon itself. In many patients, death is not due so much to obstruction 
to the entrance of air from the presence of the pseudo-membrane, as to 
the mucus and pus which collect in the trachea and bronchial tubes, and 
which are not expectorated on account of the presence of the pseudo- 
membrane and the feeble expiratory efforts of the child. In a case which 
was examined after death in the Nursery and Child's Hospital of this 
city, the false membrane was apparently not sufficient to produce a fatal 
result, but the air-passages below it were nearly filled with muco-purulent 
matter, which obstructed the entrance of air. 

Pathological Characters. — This disease is then essentially a laryn- 
gitis presenting the lesions of a simple though usually severe mucous in- 
flammation, but with a superadded element, namely, the false mem- 
brane. The coexistence of catarrhal or pseudo-membranous pharyngitis, 
tracheitis, and bronchitis is also, as we have seen, common. The impedi- 
ment to respiration, which renders croup so dangerous and fatal, is due 
not only to the presence of the false membrane, and to the mucus and 
pus which collect below it, but also to the inflammatory swelling of the 
mucous membrane and submucous oedema. In addition, there is a neuro- 
pathic element which increases the dyspnoea, and which most observers 
consider a spasmodic contraction of the laryngeal muscles induced by the 
inflammation, and hence the easier breathing in sleep, and in the general 
muscular relaxation, which precedes death. Professor Jacobi (Amer. 
Jour, of Obstet., etc., N. Y., May, 1868), however, holds that the state 
of these muscles is one of paralysis rather than spasmodic contraction. In 
his opinion, this paralysis " is secondary. It depends on the oedematous 
soaking of the posterior crico-arytenoid muscles following the oedema of 
the mucous membrane of the crico-arytenoid folds." 

In several fatal cases which I have had an opportunity to examine after 
death, I have found the appearance of the lungs quite uniform. They 
were reduced in volume (semi-collapsed) and more or less congested. 
Certain parts distant from the bronchi, especially the edges and thin por- 
tions, were collapsed completely, and certain lobules also hepatized. I 
have also observed, though in some of the cases my attention was not 
directed to it, distension of the right cavities of the heart, with blood, 
and large thrombi. From the nature of the disease, the blood is less 
oxygenated, and somewhat darker than in those who die of diseases not 
involving the respiratory apparatus. 

Diagnosis. — The diagnosis of true croup is ordinarily easy. It might 
be mistaken for spasmodic laryngitis, but more frequently spasmodic 
laryngitis is mistaken for it. The differences which will aid in differen- 
tial diagnosis are the following : Commencement abrupt and at night in 
one, gradual in the other ; presence in one, absence in the other, of a 



PROGNOSIS-TREATMENT. 547 

pseudo-membrane upon the surface of the fauces ; fragments of the mem- 
brane in the sputum in one ; character of the cough ; course of the dis- 
ease growing gradually worse in one, in the other, with few exceptions, 
rapidly improving. Trousseau speaks of the liability to error of diagnosis 
in those cases in which spasmodic laryngitis is associated with pseudo- 
membranous pharyngitis. Few physicians hesitate to designate as true 
croup those cases in which there is a croupal cough in connection with 
false membrane upon the surface of the fauces, and yet the laryngitis under 
such circumstances may be merely spasmodic. This coexistence of pseudo- 
membranous pharyngeal and of spasmodic laryngeal inflammation is, how- 
ever, probably rare, but its occasional occurrence should be borne in mind. 

True croup is readily distinguished from laryngismus stridulus, or inter- 
nal convulsions. Laryngismus stridulus is a purely nervous affection ; it 
occurs suddenly, causing great dyspnoea, or momentary suspension of 
respiration, without the fever and without the hoarse voice and cough of 
croup. When muscular relaxation occurs, the attack ceases. The differ- 
ence between the two diseases is therefore obvious. 

Prognosis. — The great mortality from true croup is universally known, 
and those physicians who report a large number of favorable cases have 
probably mistaken spasmodic croup for this disease. According to the 
statistics of Dr. Ware, nineteen out of twenty die ; but with the modern 
mode of treatment, begun early, the proportionate number of recoveries 
is probably larger than this estimate. Increase of dyspnoea, cough and 
voice becoming more hoarse, and the pulse more accelerated, indicate a 
fatal form of croup. The occasional temporary improvement due to the 
expulsion of a portion of the membrane, may lead, as we have seen, to 
error of prognosis. However, improvement continuing more than twelve 
hours is evidence of the decline of the malady. The near approach of 
death is shown by lividity with great restlessness, or pallor with somno- 
lence. If the patient recover from croup there often remains more or 
less bronchitis or broncho-pneumonia, which requires treatment, and the 
laryngitis, when its pseudo-membranous character is lost, persists for a 
time, causing more or less hoarseness, and increase of temperature. 

Treatment. — The importance of early treatment has been sufficiently 
alluded to, for if croup have continued two or three days, when first 
recognized, the chance of recovery is greatly diminished. As the danger 
is from the presence of the adventitious layer, measures should be imme- 
diately employed to prevent as much as possible its further formation and 
remove that already formed. 

The use of emetics is suggested from the nature of the disease. The 
syrup and wine of ipecacuanha and Hive syrup of the pharmacopoeia have 
been much employed as emetics in this malady, and though useful for 
spasmodic croup they are depressing and should not be employed where 
diphtheria prevails. In a locality free from diphtheria, so that there is 



548 PSEUDO-MEMBRANOUS LARYNGITIS. 

reason to believe that the patient has no blood-poisoning, which always 
produces asthenia, and that the disease is strictly local, a membranous 
and not diphtheritic croup, the emetic treatment is admissible, and will 
sometimes give partial relief. But diphtheria has at present obtained 
such a foothold in this country, it is so common both in our cities and 
rural districts, that a large majority of the cases of obstructive laryngitis 
which the American physician is called to treat are diphtheritic, and in 
diphtheria, in whatever way manifested, depressing remedies are injuri- 
ous. Hence emetics are falling more and more into disuse in this coun- 
try in the treatment of true croup. Ipecacuanha and antimonial mixtures, 
so frequently prescribed twenty-five years ago, are now almost never pre- 
scribed by the intelligent physician, when he has reason to suspect the 
presence of a pseudo-membrane upon the laryngeal surface. 

An emetic, if it be employed for pseudo-membranous laryngitis, should 
be one that acts promptly, with little depression, and its use is admissible 
only at the beginning of the disease, and at an advanced stage when there 
is great dyspnoea, and more acute measures are required to assist in ex- 
pelling the muco-pus, and shreds of pseudo-membrane, which the cough 
cannot expel, and which threaten suffocation. Sulphate of copper, in a 
dose of two or three grains, is a proper emetic under such circumstances. 
Several years since, in one case in my practice, in which there were at 
my first visit dyspnoea, croupy cough, and a pseudo-membrane over each 
tonsil, and in which I had made an unfavorable prognosis, the parents 
observing the good effects of two grains of sulphate of copper, with two 
of pulverized ipecacuanha, repeated the dose, contrary to my directions, 
every two to four hours till the following day, and the patient recovered. 
Probably, however, in ordinary cases the best emetic is the yellow sul- 
phate of mercury, prescribed in a powder of two or three grains. The 
use of this emetic in croup was prominently brought to the notice of the' 
profession in New York City by Prof. Fordyce Barker, who prescribes it 
immediately on being summoned to a case, and ordinarily with good result. 

With or without emesis other measures are urgently demanded if a 
pseudo-membrane have formed. The profession have long sought for a 
remedy which, taken internally, might by its effect on the blood and the 
inflamed surface, prevent or diminish the membranous formation, and 
also for one which employed locally might liquefy and remove it. Calo- 
mel has been largely prescribed in times gone by for its supposed " anti- 
plastic' ' action, and more recently chlorate of potassium and muriate of 
ammonium, in formulas like the following : 

9. Potassii chlorat., 

Ammonii muriat., aa 3j — 3 ij ; 

Syr. simplic, |j ; 

Aquae, §iij. Misce. 
Dose, one teaspoonful hourly. 



TREATMENT. 54:9 

Larger doses of chlorate of potassium for a child involve danger on ac- 
count of its irritating action on trie kidneys. Calomel has been properly laid 
aside, and the effect of the potassium and ammonium mixture is slow and 
uncertain. Our reliance must therefore be chiefly on inhalations, and 
these are superseding all other remedies. It has long been known that 
the vapor of slaked lime is an active solvent of pseudo-membranes, but the 
manner in which it has frequently been employed is inefficient. Many phy- 
sicians place the unslaked lime in pans or dishes, add water to it, and place 
the child so that it inhales the vapor as it rises. This is little more than 
the inhalation of steam, as any one may satisfy himself by holding a mir- 
ror or pane of glass over it, when he will perceive only a very slight de- 
posit of lime upon the glass. The proper way to employ it is with the 
atomizer. But lime is feebly soluble in water, so that the officinal aqua 
calcis contains but little, and it is necessary to employ a turbid solution 
or mixture, in order to obtain an active spray. This is apt to clog the 
glass points of the steam atomizer, though if not too turbid it can be used 
in the hand atomizer, like Delano's. I have therefore been in the habit 
of employing the officinal lime-water in the steam atomizer, but increas- 
ing its activity by adding the spray from the hand atomizer which can 
be played through the mouth-piece of the steam apparatus. 

Impressed with the importance of ascertaining what is the safest and 
most efficient solvent of pseudo-membranes, a number of experiments 
were made by Drs. Chadbourne, O'Dwyer and myself in the New York 
Foundling Asylum. We ascertained that the officinal lime-water is a 
quicker solvent than lactic acid in liquid pepsin, thirty minims to the 
ounce, for which superiority had been claimed, for it dissolved a diphthe- 
ritic pseudo-membrane half an inch long immersed in it in half an hour, 
while the other liquid required more time, and that carbonic acid, added 
in considerable quantity, did not notably impair the lime's solvent action. 
These experiments, made with the pseudo-membrane from patients 
in the asylum, were continued by Dr. Chadbourne with the fibrin of 
sheep's blood, and he has furnished me with the following statement of 
the result. The defect in these last experiments consists in the fact that 
croupous and diphtheritic pseudo-membranes contain something besides 
fibrin, to wit, altered and interlacing epithelial cells, but if the fibrin can 
be dissolved away these cells will probably be more readily detached and 
removed. 

In each experiment ten grains of fibrin were immersed in one ounce of 
the solvent used tepid. Lime-water was first experimented with in the 
following forms : 

1. Officinal lime-water. 

2. Lime-water containing much more lime than would dissolve. 

3. Lime-water rendered very turbid by passing carbonic acid through it. 

4. Lime-water with salicylic acid one half grain to the drachm added to it. 



550 PSEUDO-MEMBRANOUS LARYNGITIS. 

' ' The action of the first three was so nearly identical that no appreciable 
difference was perceptible. The solvent action of the mixture No. 2 did 
not seem to be increased by the superabundance of lime added to it, nor 
was that of No. 3 appreciably diminished by the carbonic acid passed 
through it, although it was rendered very turbid by nocculi while its reac- 
tion was still faintly alkaline. I ascertained that it required the breath to 
be exhaled three minutes through two ounces of the officinal lime-water to 
render it neutral. Mixture No. 4 containing salicylic acid, forming, no 
doubt, salicylate of lime, condensed, without dissolving the fibrin, produc- 
ing firm and hard shreds within a few minutes, in which condition it 
remained permanently. The reaction was decidedly acid. 

" Solutions of chlorate of potassium, bicarbonate of potassium, bicar- 
bonate of sodium, and borate of sodium, were used with the result of a 
very slow and limited action. The liquid pepsin of the U. S. Pharma- 
copoeia in full strength slowly but perfectly digested the fibrin. The most 
satisfactory results were from the officinal liquor potassse and liquor sodse. 
Strong solutions of these agents dissolved a small percentage of fibrin 
immediately, while no further action took place. The action was more 
satisfactory as the strength of the solution was decreased, until the two 
per cent was reached. Weaker solutions than two per cent acted slowly. 
The actions of the two per cent solutions of liquor sodse and liquor potas- 
S30 seemed identical. Either one rendered the fibrin a gelatinous mass 
within ten minutes, and subsequently totally liquefied it. 

' ' There is, in my opinion, no danger of injurious action upon the tis- 
sues of the two per cent solution of either liquor potassae or liquor sodae, 
as I have tested them upon myself, It was ascertained by experiment 
that the Codman and Shurtliff steam inhaler consumes one ounce of water 
in the boiler to two ounces of liquid in the medicine supply cup with a 
medium-size point. Therefore while for use in the hand atomizer one 
teaspoonful of the liquor potassse or liquor sodse should be added to fifty 
of water, one teaspoonful and thirty-three of water should be employed 
in the steam atomizer. ' ' 

It is to be recollected, in the treatment of croup, that the pseudo- 
membrane, by commencing decomposition, and by the pus and mucus 
which collect underneath, is more easily detached after a few days, if the 
patient live, than at first. Therefore the physician should endeavor to 
sustain the vital powers, in order that the cough may have sufficient force 
to separate this substance as soon as its fibres of attachment begin to 
loosen. A patient with croup rarely takes solid food, but he should be 
allowed beef -tea, milk, and farinaceous drinks, at short intervals. If signs 
of exhaustion arise, alcoholic stimulants are proper, and fresh air should 
also be allowed as far as is compatible with the inhalation of steam. 

As regards external treatment of the throat the late Professor Peaslee, 
of this city, in a series of papers on the pathology of croup, published in 



TREATMENT. 551 

the American Medical Monthly, 1854, says of cold applied externally : 
" We consider this of the greatest value and importance. If cold appli- 
cations are efficacious in all cases of external inflammation, they are 
scarcely less so here, where the inflamed surface is so nearly superficial. 
Cold must, however, be continuously applied to produce the desired effect. 
Applied at intervals, indeed, it rather promotes than retards the inflamma- 
tory process ; since during the intervals the temperature rises above the 
normal standard, in consequence of the reaction of the chill on the surface. 

' ' Cold water may be constantly dropped from a sponge upon a com- 
press laid over the throat of the child ; and the latter should be of only 
one or two thicknesses of linen, that evaporation may go on as rapidly as 
possible." 

In ordinary cases, cold applications over the larynx should, in my 
opinion, be used instead of poultices, especially in the early stages, 
when the pseudo-membrane is still forming. Muslin frequently wrung 
out of ice- water, or an india-rubber bag, containing pieces of ice, should 
be applied along the front part of the neck. The rubber bag or a bladder 
covered by muslin is better retained and more agreeable to the patient 
than when used without an intermediate substance. This mode of applying 
cold will be found more convenient than that recommended by Prof.Peaslee. 
The temperature of the neck may be kept constantly below the normal 
standard by ice thus applied. Cold is especially serviceable if the child 
be robust, with flushed cheeks and full and rapid pulse. In secondary 
croup, or croup occurring in feeble states of system, or presenting a sub- 
acute character, poultices or fomentations to the neck, with moderate 
counter irritation, sometimes give most relief. 

Unfortunately, as I have already stated, true croup is, in a large pro- 
portion of cases, a progressive disease. The hoarseness of the cough and 
voice and the dyspnoea gradually increase. The pulse, becoming more 
frequent and feeble, indicates the need of the most nutritious food, as the 
animal broths, and of alcoholic stimulants. The danger is, however, 
from the dyspnoea rather than asthenia. In the cities where companies 
provide oxygen, in portable apparatus, prepared for inhalation, this agent 
will be found to relieve considerably the dyspnoea in extreme cases, and 
increase the chances of a favorable result. But if the measures detailed 
above fail to give relief, and death be inevitable, if there be no other 
resource, the important question arises whether tracheotomy shall be per- 
formed. 

The published statistics relating to tracheotomy in croup are to a con- 
siderable extent unsatisfactory, since we are not informed, as regards most 
of them, at what stage of the disease the operation was performed, and 
what were the evidences of a fibrinous exudation. The most valuable and 
reliable statistics bearing upon this subject, so far as I am aware, are 
those published by Prof. Jacobi, of this city, in the American Journal of 



552 



PSEUDO-MEMBRANOUS LARYNGITIS 



Obstetrics, etc., for May, 1868, and containing the results of the cases 
which were operated on by himself and Drs. Krackowizer and Voss. 
These gentlemen are known to the profession of New York as careful and 
judicious practitioners, not likely to operate when there was probability 
of success by therapeutic measures, and not likely to mistake simple or 
spasmodic laryngitis for true croup. I have tabulated the statistics of 
their operations. 

All New York physicians are aware of the difficulty of making a dif- 
ferential diagnosis at the bedside of diphtheritic croup, and non-specific 
pseudo-membranous laryngitis, or true croup. But during the last twenty- 
five years the former has been the prevailing type of obstructive laryngitis, 
and so far as the operation of tracheotomy is concerned the attempt is 
not made to distinguish the one from the other. The surgical treatment 
is the same in both. The cases embraced in the following statistics were 
therefore in the main those of diphtheritic croup, and the results of the 
operation indicate the degree of success attainable in localities where 
diphtheria prevails, and modifies the type of the laryngitis. 



Age. Number. Kecovered. 

Under 2 years, .8 1 

From 2 to 3 years, ....... 29 5 

3 to 4 " 26 4 

4 to 5 " . . . . 34 11 

5 to 6 " . . . . . 9 2 

6 to 7 « 1 1 

7 to 8 " 3 

10 " 1 

Not given, ..... 55 15 

166 39 

Time of death after Number of Time of death after 

operation. cases. operation. 

Within 24 hours, . . 19 On 5th day, . 

On 2d day, . . 7 " 6th " . . . 

" 3d " ... 16 " 7th " . . , 
" 4th " . 15 " 9th " 

From 10th to 31st day, 



Died. 

7 
24 
22 
23 

7 



3 

1 
40 

127 
Number of 



Total, .... 
The following were the causes 
seventy-three cases : 

In operation, . 1 

Apnoea from too late operation, . 6 

Apncea, . . . . .3 

Anaemia and exhaustion, . . 4 

Diphtheria, . . . . 8 

Bronchitis .... 6 

Broncho-pneumonia, . . 15 



9 
4 

2 
1 
5 

78 



of death, as given in the records of 

Pneumonia, 5 

Broncho-pneumo. and pul. gangrene 1 
Pulmonary oedema, . . .1 
Pseud o- membranous bronchitis, 18 
Tuberculosis, . . . . 1 

Convulsions, .... 2 
Emphysema, , . ... • • 2 



Total, 



7a 



TREATMENT. 553 

The following table gives the result of tracheotomy in one hundred 
cases. It is prepared from the statistics of Gtiterbach, lately published : 
Age. Result, 

Under 1 year, 1 case fatal. 

Between 1 and 2 years, . . . 1 " 

2 and 3 " 33^ per cent recovered. 

3 and 4 " . . . . 40 

4 and 5 " 38 & " 

5 and 6 " . . . . 44$ " 

6 and 8 " 14f " 

8 and 9 " . . . .25 

From conversations which I have had with surgeons of New York, I 
am persuaded that the above tables present a more favorable result than 
could be furnished by the general surgical practice of this city. Most 
New York surgeons, however, seem to shun the operation and regard it 
with ill favor, and, did they operate as frequently as those whose names 
I have mentioned, possibly the result would be better. Statistics in Paris 
probably give nearly the true proportion of successful and unsuccessful 
operations of tracheotomy for croup, as it is performed by skilful and 
careful surgeons. Of 388 cases occurring in the practice of several Pari- 
sian surgeons, 346 died and 42 recovered ; while in the Hopital Sainte 
Eugenie, of 3*74 operated on, 310 died. (Bouchut.) 

In the New York Medical Record, during 1880, Dr. John H. Ripley 
published an interesting and instructive series of papers on tracheotomy in 
croup. The statistics of this operation as performed by himself are em- 
braced in the following tables. They show the degree of success attain- 
able by tracheotomy performed by one familiar with the operation, in 
cases which there was every reason to think would perish without surgical 
interference. His cases were recent, and of the type of pseudo-mem- 
branous laryngitis, which is now prevailing in this country. He makes 
the remark, which the experience of others fully justifies, that diphtheritic 
croup is more severe and more quickly fatal if it occur early in diph- 
theria than at a later period, when the intensity of the poison has 
diminished. He states also the interesting fact, that the common cause of 
death in cases operated on is bronchial croup, and not catarrhal bronchitis 
or broncho-pneumonia, as many suppose, and that it begins from two to 
four days after the tracheotomy. He alludes also to the fact, that nephritis 
and consequent uraemia, due to the general disease, and too often over- 
looked, is an important factor in producing the fatal result in many cases. 



Ages. 


males. 


females. 


recovering. 


deal 


Under 1 year, . 


1 


1 




2 


Between 1 and 2 years, . 


6 


2 




8 


2 and 3 " 


8 


8 


7 


9 


3 and 5 " 


10 


7 


4 


13 


5 and 7 " 


8 


5 


5 


8 



33 23 16 40 



554 PSEUDO-MEMBRANOUS LARYNGITIS. 

Causes of Death. Number. 

Bronchial Croup, 22 

Uraemia, 4 

Toxaemia, 2 

Cardiac Paralysis, 3 

Accidental plugging of tube, ... 3 

Uraemia and Respiratory Paralysis, 2 

Pneumonia, 1 

Erysipelas and Bronchial Croup, 1 

Acute Tuberculosis, * 1 

Gangrene of Wound, 1 

The facts in reference to tracheotomy in croup are the following : The 
majority of those operated on do not recover, but some live who without 
the operation would die. The operation is now more successfully per- 
formed than formerly, as the conditions of successful operation are better 
understood. Those who have operated several times, confess that their 
last cases did better than their first. Trousseau's experience was striking 
and instructive in this respect. No one, probably, ever performed this 
operation for croup more times than he, and, from constantly greater suc- 
cess, he became more and more an advocate of the operation. Trache- 
otomy, if properly performed, does not in any case shorten life, but it 
frequently prolongs it several days. It diminishes greatly the dyspnoea, 
and renders death easy. 

The objections to the operation are partly of a moral nature. The 
parents, already in the extreme of grief on account of the suffering and 
probable death of the child, consent with reluctance to an operation which 
promises not cure, but a prolongation of life. Common sympathy with 
the child and regard for the emotions of the parents should certainly have 
an influence in deciding for or against the operation. The first case of 
tracheotomy which I witnessed was such as, if common, would condemn 
this operative measure entirely. No anaesthetic was given, and, in the 
midst of the struggles of the child, large veins were severed, from which 
an abundant haemorrhage occurred. The trachea was opened, but this 
was no sooner done than death occurred, partly from the loss of blood, 
and partly from the obstruction to respiration caused by its entrance into 
the bronchial tubes. Such cases are, however, quite exceptional. Death 
rarely occurs during the operation, unless the patient be already moribund, 
and the possibility of such a result should have little weight in our decis- 
ion for or against the operation. 

Few will deny, in the light of statistics, that tracheotomy is, in certain 
cases, proper, and that a physician at times would be culpable if he did 
not strongly urge its performance. There are certain supposed contra- 
indications. One is age less than two years. It is true that those under 
the age of two years are less likely to recover after the operation than 
those above that age ; still, tracheotomy has now and then saved the 



TREATMENT. 555 

lives of the youngest infants who have croup. The possibility, there- 
fore, of success justifies the performance of the operation, however young 
the infant, when the only alternative is death. In the foregoing statistics 
it is seen that one of eight recovered who were under the age of two 
years. 

The presence of capillary bronchitis or pneumonia does not positively 
contraindicate tracheotomy, though it diminishes greatly the chances of 
a favorable issue. Nor is tracheotomy forbidden by the extension of the 
false membrane into the bronchial tubes, since it diminishes the amount 
of obstruction along which the air passes in order to reach the lungs, and 
the muco-pus as well as pseudo-membrane, lying below the point of 
operation, may be expectorated through the aperture. A decidedly 
asthenic state, as after measles or scarlet fever, indicated by feeble pulse 
and other symptoms of exhaustion, may or may not contraindicate the 
operation, whether the pseudo-membrane be limited to the larynx and 
trachea or be more extensive. 

The manner of performing tracheotomy and the subsequent treatment 
pertain to surgery, and are described in surgical works. A skilful sur- 
geon should, indeed, be employed to perform the operation when it is 
practicable. At what time in the course of the disease tracheotomy 
should be resorted to is an important practical question. Trousseau at 
one time recommended it as soon as there were certain evidences of the 
presence of a pseudo-membrane, but in the latter part of his life he did not 
operate so early. The correct rule, in my opinion, is not to operate till 
urgent symptoms arise, such as increasing dyspnoea, marked epigastric 
and suprasternal depression on inspiration, and especially commencing 
lividity of prolabia and tips of fingers. When these signs occur, it is 
unsafe to delay long. The arrangements should be previously made, 
that no time be lost. 

It is an interesting fact that a large proportion of those who die after 
tracheotomy, die of bronchitis, bronchial croup, or of pneumonia devel- 
oped after the operation. These diseases seem to be partly attributable 
to the operation, or, if previously existing, to be aggravated by it. It is 
believed that the introduction into the bronchial tubes and the lungs of 
cool air, of air not warmed by the natural circuit through the nostrils and 
larynx, may be a cause of these inflammatory complications. Some- 
times, also, the canula by pressure increases the inflammation of the sur- 
face on which it lies. Therefore, not only does the operation require 
skill in its performance, but much of its success depends on the subse- 
quent management. After the operation, the temperature of the apart- 
ment should be kept constantly at from 85° to 90°, and loaded with 
moisture. This obviates in part, but only in part, the tendency to bron- 
chitis and pneumonia. Constant attention should be given to the canula, 
to prevent its filling with mucus and pus. Most surgeons use a canula 



556 BKONCHITIS. 

with two concentric cylinders, which can be readily cleaned by removing 
the internal cylinder. The nurse, when properly instructed, can remove 
this cylinder as often as may be necessary in order to clean it. Mr. 
Lawrence, of London, and, following him, some other surgeons, prefer 
not to use the canula. The edges of the wound are kept apart by a 
wire which passes around the neck, or a little of the trachea is removed 
so as to produce a sufficient aperture. The reader is referred for par- 
ticulars regarding this mode of operating to recent treatises on operative 
surgery. 

After the operation but little medication is required. The patient 
should be kept quiet and free from excitement. His diet should be 
mainly liquid, and of the most nourishing character, with the free use 
of stimulants which the constitutional disease, diphtheria, requires. In a 
few days, if the symptoms abate, the aperture may from time to time be 
closed with the finger after the withdrawal of the canula, in order to 
ascertain if the larynx be free from obstruction. If bronchitis or broncho- 
pneumonia arise, the oil-silk jacket, with counter-irritation to the chest, 
is required, and quinine, digitalis, carbonate of ammonium, and alcoholic 
stimulants should be ordered. 



CHAPTEE IY. 

BRONCHITIS. 

Inflammation of the bronchial tubes, or bronchitis, is probably the 
most frequent disease of early life. It is usually associated with more or 
less inflammation of the mucous membrane of the nostrils, larynx, and 
trachea. We designate the disease coryza, laryngitis, or bronchitis, 
according as one or the other inflammation predominates. Sometimes 
bronchitis occurs with but slight inflammation elsewhere, and often the 
coryza and laryngitis abate while the bronchitis is still active. 

Bronchitis occurs both as a primary and secondary disease. The sec- 
ondary form is common in connection with measles, hooping-cough, 
pneumonia, and pulmonary phthisis, and it is not uncommon in scarlet 
fever, variola, remittent and continued fevers. Bronchitis is acute, sub- 
acute, or chronic, and according to its extent it is mild or severe. If the 
smallest bronchial tubes are involved, the inflammation is designated 
capillary bronchitis, a term not well chosen, but which it is convenient to 
employ in a description of the malady. Bronchitis is commonly bilateral, 
affecting the tubes on the two sides with about equal intensity. When 



ANATOMICAL CHARACTERS. 557 

due to tubercles, or to pneumonia, it is apt to be unilateral, being con- 
fined to those tubes or nearly to those which are surrounded by tubercu- 
lar or inflammatory product. 

Causes. — The causes of secondary bronchitis are obviously the dis- 
eases in connection with which it occurs. The cause of primary bron- 
chitis is the same as that of simple acute laryngitis or coryza, namely, 
sudden change of temperature from warm to cold, exposure to currents 
of air, the practice of sending children without sufficient clothing from 
heated rooms into the open air, the throwing off of bedclothes at night, 
etc. Dentition is also an occasional cause, since some children have 
attacks which coincide with the eruption of the teeth. The cough of 
dentition is usually purely a nervous affection ; but in other instances it 
is accompanied by more or less mucous secretion, and is evidently de- 
pendent on a mild catarrh. 

Anatomical Characters. — In the most common form of bronchitis 
the larger bronchial tubes only are affected. They are the seat of the in- 
flammation in most of those cases which are designated " colds" by fam- 
ilies, and which are often treated without the aid of the physician. The 
lining membrane of the bronchial tubes presents the ordinary anatomical 
characters of mucous inflammations. It is reddened uniformly or in 
patches, intensely, or in that milder degree known as arborescence, 
according to the severity of the inflammation. 

The secretion of the muciparous follicles is at first arrested, and the 
surface of the membrane is dry. In the course of a day or two the se- 
cretory function is re-established, and the surface is covered with thin and 
transparent mucus. A day or two later, the secretion becomes thicker, 
consisting of mucus and pus. Mixed with these substances are epithelial 
cells, which are exfoliated in abundance from the inflamed surface. At 
the same time the mucous membrane becomes thickened and more or less 
softened. If the inflammation be severe, the vessels of the submucous 
connective tissue are also injected. 

Usually, in about a week in the young child, in from one to two weeks 
in older children, the inflammation begins to abate. Gradually the in- 
flamed membrane returns to its normal consistence, thickness, and vascu- 
larity, and with this return to the healthy state the muco-purulent secre- 
tion abates. * 

In this, which is the simplest form of bronchitis, and most common, 
there is no ulceration, and rarely any pseudo-membranous formation, if the 
disease be idiopathic. Pseudo-membranous bronchitis is not unusual as 
an accompaniment of pseudo-membranous laryngo-tracheitis. 

Were bronchitis limited to the larger bronchial tubes, it would indeed 
be a simple affection, but unfortunately it has a tendency to extend down- 
ward. Commencing in the larger, it gradually invades the smaller tubes 
in a similar manner to the extension of erysipelas upon the skin. More 



558 BRONCHITIS. 

rarely the inflammation commences simultaneously in the larger and 
smaller tubes. Now the gravity of bronchitis is proportionate to the 
degree of its extension downward. It may stop at any point in its prog- 
ress, but if it reach the smaller tubes it is one of the most serious affec- 
tions of early life. 

The mucous membrane of the minute tubes, those next to the air-cells, 
is delicate, with but little submucous connective tissue, and it frequently, 
at post-mortem examinations, does not present to the eye those distinct 
inflammatory changes which are observed in tubes of large diameter. It 
is sometimes not notably thickened, nor its vascularity much increased, 
even when there is reason to believe from the symptoms that it was the 
seat of active phlegmasia. As we pass from these minute tubes to those 
of larger calibre, the inflammatory lesions become more distinct. The 
inflammation produces minute and abundant points of redness, and the 
membrane is evidently thickened ; often it is rough or granular. 

The minute bronchial tubes are very small, especially under the age of 
three years, and since in capillary bronchitis a large proportion of them 
are inflamed, the source of the danger is apparent. It is with difficulty 
that the patient with capillary bronchitis can, by the effort of coughing, 
free the tubes from the secretions which are constantly collecting in 
them. In weakly children, under the age of two years, expectoration is 
most difficult, and hence the great and increasing dyspnoea from which 
such patients suffer. 

In severe and unfavorable cases of bronchitis, which are chiefly those 
in which the small as well as large tubes are inflamed, the following ana- 
tomical changes commonly occur : The muco-purulent secretion, which is 
tenacious, collects more rapidly in the smaller tubes than it is expecto- 
rated by the child, whose strength begins to be exhausted. The accumu- 
lation of the secretion is chiefly in the tubes which lie in the posterior and 
inferior portions of the lung. As the obstruction from the muco-pus in- 
creases in these tubes, less and less air passes through them into the 
alveoli with which they communicate, while the quantity of air which 
passes through the unobstructed tubes into the anterior and superior por- 
tions of the lung is proportionately increased. The effect, as regards the 
state of the lung, is obvious. In cases having a fatal issue, and in which 
we are therefore able to inspect the lesion*, we find that the lower and 
inferior portions of the organ, from which air was to a greater or less ex- 
tent excluded, have a diminished crepitation, that they lie a little below 
the general level, or that certain lobules do, and that they present a con- 
gested appearance, for while they contain too little air they have an 
excess of blood. We shall also find that the upper and anterior parts of 
the organ, perhaps the entire upper lobe, contain more than the normal 
quantity of air, so as to rise above the general level. There is distension 
of the alveoli in these parts, so that they are probably visible to the 



ANATOMICAL CHARACTERS. 559 

naked eye, and may appear to be emphysematous, but this is a state dis- 
tinct from emphysema. It is merely an inflation of the alveoli to nearly 
their full capacity. 

Here and there, in the portion of lung in which the inflation has been 
incomplete, lobules may be observed which are entirely collapsed, having 
a dusky red color and no crepitation ; while in other parts, if the bron- 
chitis have continued some days, there may be nodules of pneumonia. 
The incised surface of those portions of the lung to which the access of 
air has been prevented, whether they are collapsed fully, or partially or 
not, has a reddish color from congestion, and is moist from serum and 
blood. On compressing the lung, the muco-purulent secretion appears 
upon the surface in points, having escaped from the divided ends of the 
tubes. For other facts relating to atelectasis, the reader is referred to 
the chapter in which this malady is described. 

Exceptionally even when not accompanied by laryngeal croup, fibrin- 
ous exudation occurs in the bronchial tubes, forming a delicate film, here 
and there, and readily detached from the surface underneath, while in 
rare instances it occurs as a firm and continuous membrane, forming a 
mould of the tubes, increasing greatly the dyspnoea, and constituting a 
true bronchial croup. If the patient with severe bronchitis survive, the 
inflammation of the mucous membrane soon begins to abate. The tubes 
which have been the seat of the disease, and the alveoli which have been 
secondarily involved, may return to their normal state almost immedi- 
ately ; but in other instances such anatomical changes occur in them, 
even when there is no pneumonia, nor atelectasis, that full restoration to 
their normal state is necessarily somewhat slow. When the function of a 
lobule ceases, as it does when the tube leading to it is obstructed, not 
only hyperemia occurs with or without collapse, as already stated, but its 
cells and nuclei, and perhaps other parts, begin to undergo fatty degene- 
ration. These elements become granular, somewhat enlarged and opaque, 
and here and there mixed with them are other large cells filled with oil- 
globules. These are the- compound granular cells of pathologists, and, 
occurring in this situation, are produced by metamorphoses of the epithe- 
lial cells. They are epithelial cells which have progressed more rapidly 
than others in fatty degeneration, having reached that stage of it which 
immediately precedes liquefaction. We often with the microscope ob- 
serve not only these corpuscles, but their fragments as they are dissolv- 
ing. 

Minute abscesses, usually directly under the pleura, have occasionally 
been observed at the autopsies of those who have recently had general 
bronchitis, and pathologists are not agreed as to the mode in which they 
are produced. Some of them, if not all, are evidently connected with 
the minute bronchial tubes, and the quantity of pus contained in each is 
not usually more than one or two drops. The most reasonable view of 



560 BRONCHITIS. 

their causation is that they are produced in the terminal tubes where the 
mucus and pus collect. The pus acts as an irritant and causes inflamma- 
tion, and the inflammation increases the quantity of pus. The walls of 
the tube which is now the seat of an abscess are destroyed by ulceration, 
and probably, also, some of the contiguous air-cells. The little cavity is 
soon surrounded by a delicate membrane, the same in character, though 
less thick and firm, as that which constitutes the walls of larger abscesses. 
The pus presents the usual appearance of this liquid, or it may be tinged 
by the presence of blood-cells, or again it may be thick from partial ab- 
sorption of the liquor puris so as to resemble softened tubercle. 

The abscess is ordinarily located in the centre of a collapsed lobule. 
In certain cases it approaches the surface of the lungs, so as to produce 
circumscribed pleurisy, with adhesion of the costal and visceral pleura. At 
the autopsy of such a case, on separating the adhesions and attempting 
insufflation, the air passes through the aperture, so that the lung on that 
side cannot be inflated unless the aperture be closed. Occasionally 
pneumo-thorax results from opening of the abscess into the pleural cavity. 

In severe protracted bronchitis dilatation of certain of the bronchial 
tubes sometimes results. The alveoli in the upper lobes may also be dis- 
tended beyond their physiological capacity, so as to produce emphysema, 
but as we have stated above, their maximum distension within physiolog- 
ical limits, must not be mistaken for emphysema. Emphysema in the 
upper lobes is common in feeble young children, with relaxed and weak- 
ened tissues, occurring even without any severe disease of the respiratory 
organs. It may be vesicular or interstitial. If it be interstitial the sacs 
of air often attain considerable size, lying as wedges between the alveoli, 
or like little bladders upon the surface of the lung. It is not difficult to 
understand how emphysema occurs in severe bronchitis, since the air 
partly arrested in the tubes leading to the lower lobes enters the upper 
lobes in increased volume and force. 

Symptoms. — It is evident, from the description which has been given 
of the anatomical characters of bronchitis, that its symptoms vary greatly 
in severity in different patients. It usually commences with more or less 
coryza. The symptoms are headache, flushed face, elevation of tempera- 
ture, acceleration and fulness of pulse. In the mildest cases these symp- 
toms are scarcely appreciable. The child is observed to sneeze and have 
some defluxion from the nostrils, and this is followed by an occasional 
mild, almost painless, cough, which declines in the course of a few days. 
The respiration and pulse are scarcely accelerated, and the appetite is but 
slightly impaired. There may be a little fretfulness, but the child is not 
confined to his bed or room, and usually amuses himself with his play- 
things. Auscultation in these mild cases reveals coarse mucous rales in 
the larger bronchial tubes, while the smaller tubes are free from mucus. 
Sibilant and sonorous rales are also observed, especially in the commence- 



SYMPTOMS. 561 

rnent of the bronchitis, at which time the secretion of mucus is suppressed 
or scanty. The cough in the commencement is for the same reason dry. 
It becomes looser by the second or third day, the sputum consisting of 
frothy mucus, with the admixture of pus and epithelial cells. The pus 
becomes more abundant as the disease continues. Expectoration from the 
mouth does not usually occur till after the age of four or five years ; 
under this age the sputum is ordinarily swallowed. 

The mild form of bronchitis described above, that in which only the 
larger bronchial tubes are affected, is common to all periods of infancy 
and childhood, but a severer grade of the disease is also of common 
occurrence, exclusive of those cases in which the minute branches of the 
bronchial tree are affected. It has already been stated that there is a 
tendency in bronchial inflammation to extend downward, and symptoms 
are proportionate in gravity to the degree of this extension. In severe bron- 
chitis the pulse rises to 120 or 130 per minute, and the respiration is in a 
corresponding degree accelerated. The cough is frequent and painful, 
the pain being referred to the sternum, and often there is a steady dull 
pain in this region. The face is flushed and indicative of suffering, the 
temperature is considerably elevated, and the appetite is greatly impaired 
or lost. There is frequently an exacerbation of symptoms in the latter 
part of the day. Depression of the infra-mammary region during inspi- 
ration, and dilatation of the alae nasi, accompany grave attacks of the in- 
flammation. 

Auscultation in severe bronchitis reveals the presence of rales in all 
parts of the chest, sibilant and sonorous sparingly, coarse mucous and 
subcrepitant more abundantly. 

General bronchitis or suffocative catarrh, the most dangerous form of 
this inflammation, is less frequent than bronchitis, which is limited to the 
larger tubes, or to the larger tubes and those of medium size. It may 
commence quite abruptly, but ordinarily it results from the milder form 
of the disease. The symptoms at first are such as occur in the common 
form of bronchial inflammation, but instead of abating or remaining sta- 
tionary, they gradually increase in severity till, suddenly, marked dysp- 
noea supervenes. The inflammation has now reached the minute tubes, 
and what promised to be an ordinary attack of bronchitis becomes one of 
great severity and danger. 

The respiration in severe bronchitis is short and hurried. Sixty to 
eighty inspirations per minute are not infrequent, while the pulse also is 
greatly accelerated, attaining as high a number as 140 to 160 or 180 beats 
per minute. The cough is frequent, and the sputum, which collects in 
abundance, is expectorated with difficulty. If expectorated so as to be ex- 
amined, it is found to consist largely of frothy mucus with epithelial 
cells. After a few days, if the patient live, it becomes more purulent. 
Sometimes, as in bronchitis of the adult, streaks of blood appear upon the 
36 



562 BRONCHITIS. 

mucus. In the first days of severe acute bronchitis, the temperature is 
considerably elevated, the face flushed and breathing oppressed. The 
patient is restless, moving from one part of the bed to another, seeking 
in vain for relief. The digestive function is impaired, as in all severe in- 
flammations ; the tongue is moist and covered with a light fur ; the appe- 
tite is nearly or quite lost. The nursing infant nurses with difficulty, fre- 
quently relinquishing the breast on account of the dyspnoea ; older chil- 
dren take no solid food in consequence of the anorexia and the dyspnoea, 
and even drinks are swallowed hastily and apparently without relish, since 
deglutition interferes with respiration. On auscultation in bronchitis, of 
the minute tubes, sibilant, and after a day or two subcrepitant, rales are 
observed in every part of the chest. Percussion elicits a good resonance, 
unless the substance of the lung have become involved. As the disease 
approaches a fatal termination, the pulse becomes greatly accelerated, the 
respiration is also in a corresponding degree frequent and panting, the in- 
spiration being accompanied by marked infra-mammary depression and 
dilatation of the alae nasi. The face becomes pallid, the prolabia livid, 
and the tips of the fingers livid and cool. The mucus and pus, accumu- 
lating in the air-passages, increase more and more the obstruction to the 
entrance of air, and, finally, death occurs from apnoaa. The nursing in- 
fant usually ceases to nurse for several hours before death, and a state of 
stupor commonly precedes the fatal event, due to the accumulation of car- 
bonic acid in the blood. In young infants, especially those under the age 
of six months, not only in bronchitis of the minute tubes, but in severe 
ordinary bronchitis, I have often observed, toward the close of life, inter- 
mission in the respiration. It occurs after every six or eight or ten respi- 
rations, and equals in duration the time occupied in, perhaps, half a dozen 
respiratory movements. It is, therefore, an unfavorable prognostic sign,, 
but some recover by stimulation in whom it occurs. 

The duration of acute bronchitis varies according to the extent of the 
inflammation. In the mildest form, the patient is convalescent after 
three or four days, and, in severer forms that terminate favorably, the 
disease begins, ordinarily, to decline by the close of the first week or in 
the second. The progress of bronchitis is somewhat more rapid in young 
children than in those of a more advanced age. When convalescence is 
fully established, it is not unusual for the cough to continue three or four 
weeks, though gradually declining. It is loose and painless, and is 
scarcely regarded by the patient. 

Death sometimes occurs as early as the second or third day in severe 
general bronchitis. The younger the infant, with the same extent and 
intensity of inflammation, of course the sooner the fatal result. The 
ordinary duration of fatal bronchitis is from six to eight days. If the 
patient pass beyond the tenth day, decline of the inflammation may be 
confidently expected, and recovery, unless there be a complication. 



DIAGNOSIS — PROGNOSIS. 563 

Occasionally bronchitis becomes chronic, lasting several months before 
it entirely ceases. The chronic form may result from mild, as well as 
severe, bronchitis. The acute fever and accelerated respiration which 
characterize the acute affection abate, and the general health is nearly or 
quite restored ; but an occasional cough continues, and the respiration is 
often audible, from the mucus which collects in the tubes, or from thick- 
ening of the mucous membrane. Sometimes there is moderate febrile 
movement, especially in the latter part of the day. On auscultation, 
coarse mucous, with perhaps sibilant and sonorous, rales are observed in 
the chest. 

There is great liability in chronic bronchitis to exacerbations. The 
disease often seems to be abating, and there is prospect of its speedy 
cure, when all the symptoms are intensified. The exacerbations are due 
to the fact that the bronchial surface, when it has been a considerable 
time inflamed, is very sensitive to the impression of cold. Even when 
the disease is entirely relieved, it is very apt to return by exposure to 
currents of air or changes of temperature. Chronic bronchitis occurs 
most frequently in the winter and in the spring and fall, when the 
weather is changeable, and is most intractable in these periods of the 
year. Many cases of chronic bronchitis are associated with dilatation of 
the bronchial tubes or with emphysema. The general health in this form 
of bronchitis, when not dependent on a tubercular deposit, ordinarily 
remains good. Tubercular bronchitis, which is the result of a grave dis- 
ease, does not require separate consideration. It is attended with emaci- 
ation, and is obstinate on account of the nature of the primary affection. 
It is due to the irritating effect of tubercular matter lying against the 
bronchial tubes. 

Diagnosis. — Bronchitis can ordinarily be diagnosticated by the char- 
acter of the respiration and cough. The absence of hoarseness, stridu- 
lus inspiration, and croupy cough, excludes laryngitis ; and the absence 
of the expiratory moan and of the stitch-like pain on coughing, which 
characterize pneumonia and pleurisy, excludes those diseases. Accurate 
diagnosis, however, can be most readily made by percussion and ausculta- 
tion. Examination of the chest enables us to state with positiveness, not 
only the nature, but the extent of the affection. If the inflammation be 
confined to the larger bronchial tubes, coarse rales are discovered in 
them, while finer mucous rales are absent. If the bronchitis be in the 
minute tubes, subcrepitant rales are discovered in them. Percussion 
gives clear resonance on both sides, except in those instances in which 
collapse or pneumonia has supervened. 

Prognosis. — Bronchitis, limited to the larger bronchial tubes, or to 
these and those of medium size, terminates favorably in a large majority 
of cases. Occasionally, severe inflammation, not extending to the smaller 
tubes, proves fatal in young infants, or those of feeble constitution. 



5G4 BRONCHITIS. 

Bronchitis extending to the minute tubes, is, on the other hand, a 
disease of great danger. It may be fatal at any period of childhood, but 
the younger the patients and more feeble, the greater the proportion of 
deaths. Under the age of one year, it is one of the most fatal diseases 
of early life. 

The prognosis, in the commencement of all cases of bronchitis of 
average severity in the young child, should be guarded, on account of the 
tendency of the inflammation to extend, as has been already stated in the 
preceding pages. After five or six days extension ceases, and, if during 
that time no increase in the severity of symptoms occurs, the prognosis 
is favorable. Signs which indicate an unfavorable result are increasing 
frequency of pulse and respiration, difficult and scanty expectoration, 
restlessness, a countenance expressive of suffering, and a progressively 
greater accumulation of mucus in the bronchial tubes, as determined by 
auscultation. Pallor and coldness of the face and extremities, lividity of 
the tips of the fingers, rapid and feeble pulse, drowsiness, diminution of 
cough, while the mucus and pus accumulate in the bronchial tubes, and, 
in young children, intermissions in the respiration, indicate the near ap- 
proach of death. Cases may, however, recover by proper treatment, 
although the symptoms are most unfavorable. 

It is unnecessary to mention the favorable prognostic signs of bron- 
chitis. This disease, when fully established, continues a certain number 
of days, whatever remedial measures are employed, and, if the symptoms 
do not increase in severity during the first five or six days, a favorable 
result is highly probable. The prognosis in chronic bronchitis is ordina- 
rily favorable, so far as life is concerned, provided that no emaciation 
occur. If there be emaciation, the bronchitis may be due to tubercles in 
the bronchial glands or lungs, and, of course, the prognosis is unfavor- 
able. 

Treatment. — Bronchitis may be rendered much milder, and perhap 
even prevented, by an emetic employed in the first twelve or twenty-for 
hours, in conjunction with a warm bath. The physician is not, ho 
ever, ordinarily called sufficiently early to render this treatment effectual. 
The remedial measures proper for this disease vary greatly, according to 
the stage and intensity or extent of the inflammation and the age of the 
patient. Bronchitis, limited to the larger tubes, requires simple measures. 
A laxative may be employed, with a mild expectorant, and moderate 
counter-irritation should be produced by camphorated oil, or the occa- 
sional employment of a sinapism. I have sometimes ordered for these 
cases a mixture recommended by Dr. James Jackson, of Boston, in his 
letters to a young physician. " For young children," . . . says 
he, "I employ the following : Take of either almond or olive oil, of 
syrup of squills, of any agreeable syrup, and of mucilage of gum acacia, 
equal parts, and mix them. Of this mixture, a teaspoonf ul may be given to 



TREATMENT. 565 

a child at two years of age ; a little less if younger, and increased if older, 
so as to double the dose to one in the sixth year. This may be given 
from three to six times in the twenty-four hours. Sometimes a little 
opiate must be added at night to appease an urgent cough. ' ' These cases 
also do well with simple mucilaginous drinks in conjunction with gentle 
aperients. 

Bronchitis, extending beyond the primary or secondary bronchial divi- 
sions, requires more careful watching and more decided measures. The 
abstraction of blood by leeches, or otherwise, is seldom required in the 
treatment of bronchitis. Occasionally, if the inflammation be intense and 
the symptoms urgent, moderate abstraction of blood at an early period 
might perhaps be useful, but the employment of cardiac sedatives, as 
aconite or digitalis, under such circumstances is generally preferable. 

As a rule, actively depressing agents should be avoided in the treatment 
of bronchitis in patients under the age of two years ; and, on the other 
hand, sustaining remedies are in a large proportion of cases required after 
the first two or three days. Many infants with bronchitis are sacrificed 
in consequence of the old theory, which still influences medical practice, 
that an inflammation, with its increased force of circulation, is necessarily 
best controlled by depletory and sedative measures. Remedies too de- 
pressing are prescribed, and with a less favorable result than would fol- 
low the use of sustaining measures or even a strictly expectant course of 
treatment. 

What is, therefore, the proper mode of treating bronchitis, severe or 
of ordinary gravity, occurring in infancy and childhood ? It is supposed 
that the physician is called when the inflammation is fully established, or 
that, if he have seen the patient at the commencement, and have prescribed 
an emetic, it has failed to throw off the disease. A large emollient poul- 
tice not thicker than the cover of a book, so wet as to produce constant 
moisture of the surface, and sufficiently irritating to produce constant 
redness without necessitating its removal, should be applied to the front, 
sides, and back of the chest, and over it an oil-silk jacket placed. I prefer 
a poultice of the following : 

B. Pulv. sinapis, 1 ss ; 

Pulv. semin. lini, fviij. Misce. 

Local treatment in bronchitis is very important. The exact mode of 
applying it, or the substances used, matters little, provided that it meets 
the indication, which is twofold — namely, derivation to the surface, and 
the application to it of warmth and moisture. Such applications are 
found, by experience, to give most relief. "Warmth and moisture are 
furnished by cataplasms most conveniently, or by warm -water applications 
under oil-silk. Instead of the sinapised poultice, it is better for infants 
under the age of six months to apply a light flaxseed poultice with cam- 
phorated oil smeared over its under surface. 



566 BRONCHITIS. 

Derivation to the surface, early made and repeated, tends to check the 
downward extension of bronchitis ; but it is not advisable to vesicate, or 
to produce anything more than moderate and continued redness. Often 
improvement in symptoms is observed, especially less dyspnoea and rest- 
lessness, immediately on the employment of the local measures recom- 
mended above. If the bronchitis have that severity that there is a de- 
cided febrile movement, accelerated respiration or pain on coughing, this 
external treatment should in my opinion always be employed, but if the 
disease be so mild that these symptoms are absent the case will probably 
do well without it. The internal treatment appropriate for bronchitis 
varies according to the age of the patient and the character of the inflam- 
mation, whether it be primary or secondary. The following formulae will 

be found useful : 

B. Ammon. carbonat., gr. viij ; 
Syr. bal. tolut. , § ss ; 
Aquae, 1 iss. Misce. 
Dose, one teaspoonf ul every two or three hours for an infant of three months. 
Instead of the carbonate, twice its quantity of muriate of ammonia may be 
prescribed. 

Infants of this age usually require also alcoholic stimulants, as six or 
eight drops of brandy every hour or two. 

B. Spts. aether, nitr., 3j ; 
Syr. ipecacuanb.ee, 
01. ricini., 5a 3ij ; 
Syr. bal. tolut., fj. Misce. 
Dose, one teaspoonf ul every two to four hours to an infant one year old with 
acute primary bronchitis. 

B. Syr. ipecacuanha?, 3 i j ; 
Potas. acetat., gr. xvj-3ss; 
Syr. simplicis, 3 xiv. Misce. 
Dose, one teaspoonful to an infant of six months with acute primary bronchitis. 

Medicines which exert a greater controlling effect upon the action of the 
heart than those which we have mentioned, are often required during the 
progress of severe bronchitis, namely, in those cases in which the patient 
is weakly, while the pulse is unusually rapid and temperature elevated. 
One or two drops of tincture of digitalis may be added as a heart tonic to 
each dose of the prescription for a patient of six months to two years. 
For children over the age of two years, whose previous health has been 
good, aconite is preferable as a cardiac sedative. The following will be 
found a useful recipe for a robust child of five years : 

B- Tinct. rad. aconit., gtt. xvj ; 
Syr. scillae composit., 3 ij ; 
Syr. bal. tolut., 3 xiv. Misce. 
Dose, one teaspoonful from two to four hours. 

The medicine should be omitted or given at a longer interval if the 
frequency of the pulse be reduced. I have nearly abandoned the use of 



TREATMENT. 567 

veratrum viride for the bronchitis of children on account of its very de- 
pressing effect. If there be restlessness, Dover's powder, paregoric, or 
syrup of poppy should be administered with the expectorant mixture or 
separately. Squibb 's liquid Dover's powder, the tinct. ipecac, comp. is 
a useful and convenient remedy to procure sleep in these cases. It may 
be given to an infant of one year in one-drop doses. Agents more de- 
pressing than ipecacuanha should not be administered to infants under the 
age of six months, even in the commencement of acute bronchitis. 

The effect of the stronger cardiac sedatives, as aconite and veratrum 
viride, in the bronchitis of children, should be carefully watched. In 
general they should be administered only during the first three to five 
days ; but if the child be robust, with full and strong pulse, they may be 
continued longer. In many cases of primary and secondary bronchitis 
during its active period, quinine administered with or without digitalis, is 
an invaluable remedy, as a substitute for aconite or veratrum viride. 
Like those agents, it diminishes the temperature and the frequency of 
pulse, while it acts as a general tonic and preserves the strength of the 
heart's contractions. This effect of quinine, which has only in recent 
years been brought prominently to the notice of the profession, and is 
now accepted as a valuable fact in therapeutics, indicates an important 
use for this agent in several of the most common and severe diseases of 
children, as bronchitis, pneumonitis, scarlatina, and diphtheria. While 
it may not reduce the frequency of the pulse as quickly as aconite, or to 
the same extent, it has in my practice been equally effectual in reducing 
the temperature. As many as six or eight grains may be administered 
daily in divided doses to a child of two or three years. If this agent be 
properly administered, and the dose reduced as the fever abates, cincho- 
nism, at least so as to be injurious, seldom occurs. As the active inflam- 
mation begins to abate, simple expectorant mixtures may be given, as 
syrup of squills or ipecacuanha in spiritus Mindereri. At this stage of 
bronchitis, it is usually best to commence the use of stimulating expecto- 
rants, and they are required in nearly all cases of advanced bronchitis. 
In secondary forms of the disease, as when it occurs in connection with 
hooping-cough or measles, such expectorants should be employed from 
the first ; and also if there be a state of feebleness or cachexia, although 
the bronchitis be primary. The following will be found useful prescrip- 
tions, the digitalis being employed, as it is the best heart tonic with which 
we are acquainted, reducing the frequency of the heart-beats while it 
gives them more force : 

B. Tinct. digital., gtt. xij ; 
Ammon. muriat., 3ss; 
Syr. bal. tolut., 
Aquae, aa 3 j. 
Dose, one teaspoonful every two hours to a child of one year. 



568 BRONCHITIS. 

5. Ammon. carbonat., gr. xvj-xxiv ; 
Tinct. digital., gtt. xxiv ; 
Syr. senegse, 3 ij ; 
Ext. glycyr., 3 ss ; 
Aqua?, 3 xiv. Misce. 
Dose, one teaspoonful every two or three hours to a child of two years. 

During convalescence the medicine should be administered less and less 
frequently, or in smaller doses. Emetics in ordinary cases of bronchitis 
are not required, except in the commencement. In severe bronchitis, 
however, especially when the smaller tubes are inflamed, they sometimes- 
appear to be useful. The cases which justify their administration are 
those in which mucus and pus collect in the tubes more rapidly than they 
are expectorated, so as to give rise to urgent dyspnoea. An emetic admin- 
istered under such circumstances may give prompt and decided relief. 
The object to be gained is obviously very different from that in the com- 
mencement of bronchitis, and such agents should be employed as act. 
promptly, with the least possible depression. Turpeth mineral or sul- 
phate of copper is, then, the proper emetic. The former may be given in 
a dose of three grains ; the latter, of one or two grains to a child five 
years old. If there be considerable strength of pulse and heat and dry- 
ness of surface, ipecacuanha may be administered. If there be evi- 
dences of exhaustion stimulants may be prescribed immediately before 
and after emesis. Infants oppressed by the accumulation of mucus and 
pus may sometimes be relieved by tickling the fauces with the finger. 
This provokes vomiting, and the viscid mucus which collects at the 
entrance of the glottis is removed by the finger. 

In secondary bronchitis, whatever the age, in primary or secondary, oc- 
curring in infants or feeble children, the diet should, as a rule, be nutri- 
tious through the entire disease. Robust patients, or those who have had 
ordinary health, if over the age of two years, and affected with primary 
bronchitis, should have light diet, chiefly farinaceous, in the first days 
of the attack, after which animal broths are proper. Whatever food is 
given in severe bronchitis must be in the form of drinks, since the appe- 
tite is lost, while the thirst is such that liquids are less likely to be re- 
fused. 

In primary bronchitis, if mild or of ordinary severity, alcoholic stimu- 
lants are not required. In secondary bronchitis they are often needed, 
and also in severe primary bronchitis, if there be dyspnoea with evidences 
of prostration. The occasional loose cough which is often present during 
the period of convalescence requires but little treatment ; either no 
medicine or a gently stimulating expectorant may be given. 



ATELECTASIS. 569 



CHAPTEK Y. 

ATELECTASIS. 

In certain new-born infants the lungs do not undergo inflation, or only 
a portion of the lobules are inflated, to wit, those in the upper lobes, 
while the remainder of the organ continues unchanged from the foetal 
state. This non-inflation of the lung is designated congenital atelectasis. 
It is not due, unless in rare instances, to any defect or vice in the respira- 
tory apparatus, for at the autopsies of cases which have ended fatally, as 
most cases do, at an early period, insufflation is easy, there being no 
occlusion of the air- passages, nor unusual adhesion of the walls of the 
alveoli to prevent the admission of air. Physicians have believed that in 
some instances they discovered the cause in an enlarged thymus gland, 
which compressed the lower part of the trachea, but this cause, in my 
opinion, does not exist or is exceptional, for although the thymus at birtli 
is large, having nearly the size of an unexpanded lung, it has not seemed 
to me to be unduly enlarged in most atelectatic cases which I have exam- 
ined after death. 

The ordinary proximate cause of atelectasis neonatorum is feebleness of 
inspiration, whether due to general debility, as in infants born prema- 
turely, or weakened by placental haemorrhage in the last months of foetal 
life, or, as is frequently the case, to injury of the brain and consequent 
impairment of the function of the pneumogastrics during birth. I have 
more fully treated of this form of atelectasis in the chapters which relate 
to the maladies incidental to the birth of the child, and to these the reader 
is referred. 

Acquired Atelectasis, or collapse of lung, is less extensive than con- 
genital atelectasis, being confined to a portion of a lobe, and often to only 
a few lobules. It occurs chiefly during the period of infancy and in fee- 
ble children. It is a common malady, in foundling asylums, in wasted 
infants who perish before the close of the first year. I have frequently 
at the autopsies of such infants observed it along the thin inferior mar- 
gins of the lower lobes, and in the tongue-like prolongation of the left 
upper lobe. In this class of cases, catarrh of the bronchial tubes appears 
to have little or no agency in causing the collapse. The cause is found in 
the impaired functional activity of the lungs. In the state of debility the 
heartbeats feebly and the stream of blood from it to the lungs is small and 
slow, so that the inspiration of a small amount of air suffices for its decar- 
bonization. The inspirations also are seen to be feeble, causing little ex- 



570 ATELECTASIS. 

pansion of the walls of the thorax. Consequently the entire lung is im- 
perfectly inflated, as is seen in fatal cases, but the distant thin portions of 
the organ are least expanded. These receiving little or no air, soon begin 
to contract from the presence of the elastic tissue, and collapse or atelec- 
tasis ensues. 

This has been the most common form of atelectasis in cases of this 
malady, which I have observed in foundling asylums, and it probably oc- 
curred in the manner which I have described. 

Another cause of acquired atelectasis to which all writers allude is bron- 
chial catarrh, which commencing in the larger tubes extends downward 
into those of smallest size. By the swelling of the mucous membrane, 
and the accumulation of viscid muco-pus which cannot be expectorated, 
certain of these tubules become occluded, so that the inspired air is shut off 
from the alveoli situated beyond them. Occlusions are obviously most 
apt to occur in the bronchitis of feeble infants, whose cough has little ex- 
pulsive force, so that debility is also a factor in the production of this 
form of atelectasis. The portion of lung withdrawn from the respiratory 
function soon collapses, the air which it contained being probably in part 
expired, but chiefly absorbed. 

Atelectasis is not, however, so important or frequent a complication of 
bronchitis as was formerly supposed, for catarrhal pneumonitis due to ex- 
tension of the inflammation from the bronchioles into the lung has been 
mistaken for it. Solid non-crepitant nodules or portions of lung are fre- 
quently observed at the autopsies of infants who have perished of severe 
bronchitis, and these may be atelectatic or pneumonic, but they have in 
my observations been more frequently the latter than the former. 

The possibility of insufflating these solid portions when removed from 
the body after death, was till within a few years regarded as the decisive 
proof of atelectasis. But this is now known to be no test, since a lung 
solidified by recent catarrhal pneumonitis can be almost as readily inflated 
as that which is collapsed. Nevertheless, the inflated pneumonic lung is 
more solid and resisting when pressed between the thumb and fingers than 
is the collapsed lung. The decisive proof is afforded by the microscope, 
by which cell-proliferation is discovered within the alveoli in catarrhal 
pneumonitis, while it is lacking in simple collapse. An increase of the 
dyspnoea not infrequently occurs in severe infantile bronchitis, without 
either pneumonia or collapse from the accumulation in the bronchioles of 
the secretion which is with difficulty expectorated, but if dulness on percus- 
sion and other physical signs indicate solidification of the lung at some 
point, of course pneumonia or collapse has occurred. If a sufficient amount 
of lung be involved to produce well-marked physical signs the disease is in 
most instances pneumonia and not collapse, though it may be the latter. 
Both these pathological states may, however, occur in the same lung as 
complications of severe bronchitis. The severe paroxysmal cough of per- 



ANATOMICAL CHARACTERS. 571 

tussis, especially when accompanied by considerable secretion, is apt to 
produce collapse of portions of the lower lobes, while it causes emphy- 
sema in the upper lobes. 

Symptoms. — Atelectasis resulting from bronchitis gives rise to no new 
symptoms. So far as it has any appreciable effect it aggravates certain 
symptoms of the primary disease, but as it is ordinarily limited to a small 
area this effect is not very marked. When a bronchial tube is so occluded 
by muco-pus that the alveoli with which it communicates collapse, there 
is ordinarily, at the same time, more or less accumulation of this secretion 
in other tubes throughout the lungs. Therefore, the entrance of air into 
the alveoli with which these tubes communicate is slow and difficult, but 
usually without complete obstruction, and without true atelectasis, but 
with a semi-collapse such as we observe in fatal croup. This explains the 
dyspnoea which is present in these cases. If the secretion be expectorated 
from these tubes the dyspnoea abates, even if the plug which has com- 
pletely occluded a tube and the consequent atelectasis remain. 

Atelectasis occurring in wasted and feeble infants, in consequence of 
the diminished force of the inspirations, does not in most instances give 
rise to any prominent symptom, since it occurs chiefly in distant thin 
portions of the lungs. I have observed an occasional short, nearly pain- 
less cough in such infants, when the autopsy revealed no pulmonary 
lesion except the atelectasis. 

Anatomical Characters. — The portion of lung which is affected with 
recent atelectasis has a dark-brown or dark- bluish color. It is depressed 
below the general level of the lung, is firm and non-crepitant on pressure, 
and its incised surface is smooth. Hyperemia supervenes, for a portion 
of lung in which the circulation continues, but from which air is excluded, 
becomes congested. In acquired atelectasis the congestion is especially 
marked, since the vessels which have been adapted by growth for a larger 
area are compressed into one of smaller extent, so that they become tor- 
tuous and bulging within the lumina of the alveoli, while the free flow of 
blood through them is retarded by the constriction of the elastic fibres of 
the lung. An obvious and certain result of the hypersemia is the transu- 
dation of serum into the alveoli, producing oedema. This union of pul- 
monary hypersemia with oedema by which air is excluded from the alveoli 
constitutes the state known to pathologists as splenization, and in propor- 
tion as it occurs the lung depressed by the atelectasis rises toward the 
general level. It may even rise above it, and it now has a doughy elastic 
feel. The pathology of these cedematous atelectatic spots, heretofore ob- 
scure, has been clearly explained by Rindfleisch. 

If the patient live, and the atelectatic lobules do not soon return to a 
state of health, they undergo further changes. Rindfleisch says : 
" From the series" (of changes, provided inflammation do not occur) 
" we especially render prominent two conditions, inveterate oedema and 



572 ATELECTASIS. 

slaty induration. But inflammation does commonly occur after a time in 
a collapsed lung." Those who are familiar with the post-mortem exam- 
inations of infants will fully agree with Rindfleisch when he says : 
" Splenization, quite generally taken, appears to present extraordinarily 
favorable preliminary conditions for the occurrence of inflammatory 
changes. It may directly represent the initial hyperemia of acute inflam- 
mation, and be followed by lobular and lobar, but constantly catarrhal in- 
filtrates. " It is well known by pathologists that protracted congestion, 
active or passive, of whatever organ or tissue, is very apt to pass from a 
state of simple stasis of blood to one of cell-proliferation, and the atelec- 
tatic lung, as I have myself observed at autopsies, affords a common ex- 
ample of this. I have several times made or have procured microscopic 
examinations of the atelectatic portions of lungs of infants who had died, 
for the most part, in a wasted and enfeebled state, and have found in 
them clear evidence of the presence of a catarrhal pneumonia. The in- 
teresting fact, therefore, must be recognized, that atelectasis frequently 
passes to a state of inflammation, so as to present the characters of ordi- 
nary hypostatic pneumonia, and no doubt undergo the same subsequent 
changes. 

Atelectasis, when recent and simple or uncomplicated, may soon disap- 
pear by the expectoration of the obstructing secretion, if such be present, 
or if there be no obstruction, by increased force of inspiration. If it do 
not soon disappear it undergoes one of the ulterior changes alluded to 
above, and henceforth the symptoms and history are those of the new 
malady which has supervened. 

Treatment. — The treatment of acquired atelectasis is simple. If it be 
recent and there be evidence that it is due to the accumulation of the 
secretion in the bronchial tubes, an emetic, which acts promptly and with 
the least possible depression, may be very useful. It is especially indi- 
cated if there be little or no pneumonia, the strength not greatly reduced, 
and there be dyspnoea with insufficient decarbonization of blood in conse- 
quence of the abundance of the secretion in the smaller tubes. An 
emetic which acts promptly and with little prostration may aid greatly in 
establishing the respiratory function in collapsed lobules, by expelling the 
obstruction, and producing a freer and deeper inspiration. One of the 
best if not the best emetic for this purpose is sulphate of copper, given in 
a dose of one to two grains to a child of one year. With or without the 
use of the emetic our main reliance must be on sustaining and stimulating 
measures, by which the cough, the cry, and the inspirations acquire more 
volume and force. Most cases require alcoholic stimulants and the am- 
monium carbonate. Rubefacient applications to the chest are also com- 
monly employed, and are probably useful. 



PNEUMONITIS. 573 



CHAPTEE YI. 

PNEUMONITIS. 

In children over the age of three years, pneumonitis differs but little in 
form or phenomena from that of the adult, being ordinarily primary ex- 
cept as it depends on an irritant, as tubercles, and extending rapidly ovev 
one or more entire lobes. In those under the age of three years it is, on 
the other hand, as a rule, a secondary affection, and limited to a part of 
a lobe. Most writers, until recently, have classified cases according to 
their origin as primary and secondary, or their extent as lobar and lobular, 
or their duration as acute or chronic. A better classification, having an 
anatomical basis, is that into catarrhal, croupous, and interstitial. 

Catarrhal pneumonitis consists in an inflammation of the air-cells, with 
an abundant proliferation of epithelial cells within them, and the exuda- 
tion of serum, but not of fibrin. The secondary and lobular pneumoni- 
tis of young children, alluded to above, is usually of this character. 
Croupous pneumonitis consists also in an inflammation of the alveoli, but 
with an abundant formation of pus-cells within them, and the exudation 
of fibrin and serum. The lobar and primary pneumonitis of advanced 
children and adults is commonly of this character. In both catarrhal and 
croupous pneumonitis, therefore, the solidification of the lung and exclu- 
sion of air are due mainly to the newly formed cellular elements with 
which the alveoli are filled, though the source and nature of these cells 
differ in the two diseases. Interstitial pneumonitis consists in an inflam- 
mation and hyperplasia of the connective tissue of the lungs. It is the 
chronic pneumonia of authors, resembling in many respects, in its 
anatomical and clinical characters, cirrhosis of the liver. The inflamma- 
tion which produces this result is subacute, and in nearly all cases is de- 
pendent on some persistent local disease in the minute bronchial tubes or 
lungs, as softened or cheesy tubercles, cancer, abscesses, protracted in- 
flammation of the alveoli or bronchioles, whether produced by the inhala- 
tion of dust of an irritating nature or other cause. Interstitial pneumonia 
is much more rare in children than adults, and, as it presents no peculiar 
features in them, it need only be alluded to in this connection. 

Causes. — Croupous pneumonitis in most cases results from that com- 
mon cause of inflammations — namely, taking cold. It commences as a 
primary disease within a few hours after exposure. Catarrhal pneumo- 
nitis, in exceptional instances, also commences abruptly as a primary dis- 
ease from the same cause, but being, probably in nine cases out of ten, 



574 PNEUMONITIS. 

secondary, it commonly results from antecedent pathological states, 
which we will enumerate. 

First. Many cases result from bronchitis. The inflammation extending 
downward engages the minute bronchial tubes, and from them traverses 
the alveoli of one or more lobules. This is the broncho-pneumonia of 
children described by authors ; it occurs most frequently between the 
ages of six and eighteen months. 

Secondly. Hypostasis, or passive congestion, is an important factor in 
the causation of many cases, and in feeble infants it is not infrequently 
the sole cause. Infants with feeble health and languid circulation, lying 
in their cribs day after day with little movement of the body, are very 
liable to passive congestion of the depending portions of their lungs, and 
this by and by eventuates in a cell-proliferation within the alveoli — in 
other words, a pneumonia presenting some peculiarities, but of the 
catarrhal form. In foundling hospitals, where feeble infants are received 
and treated, this is one of the most frequent pathological states, and is 
the prevailing form of pulmonary inflammation. It is sometimes de- 
scribed as hypostatic pneumonia. Hence physicians, whose observations 
have been largely in such institutions, have almost ignored any other form 
of pneumonia in infants. Billard, a close and accurate observer, wrote 
nearly half a century ago : " Pneumonia of infancy presents peculiar 
characters, in which it differs from the same affection in adults. Instead 
of being an idiopathic affection arising from irritation developed in the 
pulmonary tissue under the influence of atmospheric causes, which often 
excite the disease, the pneumonia of young infants is evidently the result 
of a stagnation of blood in their lungs. Under these circumstances this 

blood may be regarded as a kind of foreign body It would, 

therefore, appear that inflammation of the lungs, which produces hepatiza- 
tion, arises in infants, in general, from some mechanical or physical 
cause. ' ' Valleix also states that he found the lesions of pneumonia in a 
majority of the infants who died in the Hopital des Enfants Trouves. 
The statements of Valleix are applicable also to the Infants' Hospital, and 
Nursery and Child's Hospital, of this city, as regards those cases in 
which death results from chronic disease. We shall see hereafter that 
hypostatic pneumonia is one of the most common complications of chronic 
infantile entero-colitis, the summer complaint of the cities. 

Thirdly. Catarrhal pneumonia of infants sometimes results from col- 
lapse. It is not unusual to find, at the autopsies of infants who have 
died in a state of emaciation and feebleness, portions of the lungs remote 
from the bronchi collapsed, as, for example, the thin edges of the inferior 
lobes, and the tongue-like process of the upper lobe, the process which 
lies over the heart. The immediate cause of the collapse has been a 
bronchitis, or it has resulted directly from the general weakness of the in- 
fant, and its feeble respirations. Now, a collapsed lung soon becomes 



causes. 575 

affected by passive congestion. The functional activity of an organ favors 
circulation through it, and if the function be abolished the flow of blood in 
the part is retarded, and stasis more or less complete results. The 
hypersemic state of collapsed pulmonary lobules presents the same 
anatomical condition, for the supervention of pneumonia, as occurs in 
cases of hypostatic congestion. Consequently, cell-proliferation soon be- 
gins in the collapsed alveoli, the volume of the affected lung increases, 
and it becomes firmer and more resisting to the touch, and the micro- 
scope reveals the characters of a subacute but genuine catarrhal pneumo- 
nitis. I have made or have procured microscopic examinations of a con- 
siderable number of such specimens, and have found the alveoli more or 
less filled with cells of the epithelial character. (See article Atelectasis.) 

In rare instances in infancy and childhood pneumonitis results, as it 
more frequently does in the adult, from an embolus detached from a clot, 
which had formed in some remote vein, in consequence of arrest of cir- 
culation in it, by inflammation of the contiguous tissues. This is de- 
scribed by writers as a distinct form of pneumonitis, designated embolic 
or embolismal. A specimen showing this p IG 24 

mode of causation was exhibited by me at g» 

the New York Pathological Society, in %£k 
February, 1868. An infant, born January ?3§p 

22, 1868, of strumous parents, had been ft) *? c /> i^'t^ $£ ^o^- 
fretful, but without appreciable ailment 1, "\^f-\4 ^ ? $^ 
till February 3d, when inflammation of the Bf ^ % *i ^^g 

connective tissue occurred on the anterior S§}f S$IS|g^TO| ,^r[ 
aspect of the left leg, a little below the SS^S % ?M \, 

knee. This extended downward, suppu- ^ ; ^§° ' i IBLj s* * 
rated, and the pus was evacuated February 

oth. In the mean time three other similar inflammations occurred, two 
on the right foot and leg, and the other over the parietes of the chest in 
the right infra-mammary region. Suppuration occurred in all of these. 

On February 8th this infant was suddenly seized with extreme dyspnoea, 
and died in a few hours. Numerous minute puriform collections (for- 
merly called metastatic abscesses) were discovered in each lung, most of 
them scarcely larger than a pin's head. One of them on the right side 
in the middle lobe connecting with a bronchial tube had ruptured into the 
pleural cavity, causing pneumothorax, collapse, and incipient pleuritis. 

The annexed figure exhibits the microscopic appearance of this soft- 
ened fibrin, which, to the naked eye, so closely resembled pus. 

On account of the speedy death, the emboli had produced in the lo- 
bules where they had lodged little more than congestion or the first 
stage of pneumonitis around them. Had the infant lived longer, doubt- 
less the ferments or the vibriones, which some consider the irritating ele- 
ment of emboli, would have caused a greater amount of pneumonia. 



576 PNEUMONITIS. 

Anatomical Characters. — Nothing need be added in this connection 
to what has already been said, in reference to interstitial and embolismal 
pneumonias. Being comparatively rare in children, they present the 
same anatomical characters as in the adult. That unimportant form of 
pneumonia called pleurogenous, and which consists in a croupous inflam- 
mation of the superficial infundibula of the lung underneath an inflamed 
pleura, occurs in children as well as adults. Being secondary to the pleu- 
ritis, and produced by extension of the inflammation of the pleura, 
it gives rise to no appreciable symptoms, on account of its slight 
extent, and as it presents no peculiar features in the child, it need only be 
alluded to. 

Croupous pneumonitis, which we have stated is the ordinary form of 
pulmonary inflammation in children over the age of five years, has the 
same anatomical characters as in the adult. It ordinarily involves an en- 
tire lobe. It is more frequent in the right than left lung, and in which- 
ever lung it occurs its most frequent seat is the lower lobe. The inflam- 
mation may, however, be limited to an upper lobe, especially on the 
right side. It ordinarily commences near the root of the lung, and 
extends forward. 

Croupous pneumonitis presents three stages, that of congestion, red 
hepatization, and gray hepatization. In the stage of congestion the ca- 
pillaries in the walls of the alveoli are greatly distended, bulging forward 
in loops within the alveolar spaces so as to diminish them, and a viscid 
albuminous fluid begins to exude, in which points of extravasated blood 
appear. The affected lung in this stage has a deep-red color, its elas- 
ticity is greatly diminished, and its density and weight increased. On 
account of the reduced size of the alveoli from the bulging of the 
alveolar walls, and the viscid fluid within the alveoli and terminal 
bronchial tubes, the function of the affected lobe is nearly lost, and hence 
the dyspnoea which patients experience in the first stage of the inflam- 
mation. 

The second stage is characterized by the continued and increased 
escape of the liquor sanguinis and red and white corpuscles through the 
stigmata or little apertures which exist normally in the walls of the capil- 
laries. The inflamed alveoli and the minute bronchial tubes which ter- 
minate in them are filled with this pneumonic exudation. The relative 
proportion of the elements of the blood in the exudate varies in different 
cases. Fibrin is always present, immediately coagulating in delicate fila- 
ments within the interstices of which the corpuscles are lodged. The 
white corpuscles in some cases are much in excess of the red, while in 
others the red predominate. The lung in the second stage contains no 
air, has a greater specific gravity than water, is friable so as to be readily 
torn and penetrated by the finger. The torn surface in the adult presents 
a granular appearance, each granule being the contents of an air-cell. In 



ANATOMICAL CHARACTERS. 577 

the child the granules are not distinct on account of the small size of the 
air-cells, but the volume of the inflamed lobe is somewhat increased as in 
the adult. 

The stage of gray hepatization succeeds, in which the volume of the 
lung is still greater. The change of color is due partly to the compres- 
sion of the capillaries by the inflammatory material, partly to the de- 
struction of the red corpuscles, and disappearance to a greater or less 
extent of their coloring matter, while the white corpuscles (pus-cells) re- 
main, but more to commencing fatty degeneration in the exudate prior to 
its liquefaction. In favorable cases the lung soon returns to its normal 
state, the liquefied substance which filled the alveoli being in part ab- 
sorbed, in part expectorated. 

Croupous pneumonitis often causes inflammation of the portion of the 
pleura which covers it. Pleuritis developed in this way is circumscribed, 
but it frequently extends beyond the inflamed parenchyma to the dis- 
tance of one or two inches. Bronchitis is also a common accompani- 
ment. It may be general, in which case it occurs independently, or be 
limited to the tubes lying within the inflamed lung, in which case it results 
like the pleuritis from the pneumonitis. It is seen from this description 
that the pus-cells which are produced so abundantly in the alveoli are be- 
lieved to be chiefly exuded white corpuscles of the blood. Possibly some 
of them may be produced by proliferation of the epithelial cells, which 
line the alveoli, in the same manner as they are believed to be produced 
in the bronchial tubes. 

Catarrhal pneumonitis, which is, as we have stated, for the most part 
the lobular pneumonitis of writers, and which, with an occasional excep- 
tion, is the form of inflammation in children under the age of five years, 
presents not only clinical but anatomical features, which distinguish it 
from the croupous form of the disease. Those who have witnessed few 
post-mortem examinations of young children, and whose views of the 
lesion are influenced by the expression lobular, are apt to suppose that 
there is an alternation of inflamed and healthy lobules, so that the surface 
of the lung presents an appearance not unlike mosaic work. This is a 
mistake. Although an entire lobe is seldom inflamed, as in croupous 
pneumonitis, the inflammation commonly extends over more or fewer con- 
tiguous lobules, but we find certain lobules in the midst of the inflamed 
area which are but slightly affected or have escaped entirely. The extent 
of the inflammation is ordinarily from one to three inches, but I have 
seen a nodule of true catarrhal pneumonia not larger than a pea, while 
every other portion of the lung was healthy. On the other hand, almost 
an entire lobe may appear hepatized to the naked eye as in the croupous 
inflammation, but by a careful examination certain lobules will be found 
unaffected. Thus, in a case in the Nursery and Child's Hospital, in 
which death occurred at the age of one year from pneumonitis superven- 
37 



578 PNEUMONITIS. 

ing upon pertussis, an entire lower lobe, with the exception of a little of 
its anterior border, presented the appearance and feel of red hepatization,, 
but a careful microscopic examination revealed not only the absence of 
fibrin in the exudate, showing the catarrhal nature of the inflammation, 
but also certain lobules in the midst of the inflamed lung which were not 
involved. 

The first change occurring in a lung invaded by catarrhal pneumonitis 
is congestion, whether active, as in the common form of the disease, in 
which the inflammation has extended into the lung from the bronchioles,, 
or passive, as when the inflammation results from hypostasis or collapse. 
An exudation of serum, but not of fibrin, follows, and soon the epithe- 
lial layer which lines the alveoli begins to swell. The nuclei of the epi- 
thelial cells divide, the cells themselves forming large round cells with 
vesicular nuclei. These cells, to which the solidification of the lung is 
mainly due, are, therefore, on account of their origin and appearance, 
regarded as epithelial. The alveoli in catarrhal pneumonitis, it is seen,, 
are filled with an inflammatory product quite different from that in the 
croupous inflammation. 

Inflammation of the pleura over the inflamed lung, so common in croup- 
ous pneumonia, and which gives it the name pleuro-pneumonia, by which 
it is sometimes designated, occurs less frequently in this disease. The 
seat of this inflammation is ordinarily the posterior part of the lungs, even 
when it results from extension of the inflammation from the bronchial 
tubes. When resulting from collapse, it affects chiefly those lobules 
which are remote from the bronchi, and which the air enters only by a 
long circuit. 

Catarrhal pneumonitis, when it arises from extension of acute inflam- 
mation of the bronchioles, is acute, but in those forms of the disease which 
supervene upon passive congestion it is subacute. The alveoli are less 
distended by inflammatory products than in croupous pneumonia, not only 
from the absence of fibrin, but from a less amount of cells. Hence the 
volume of the inflamed lung is not so great as in that disease, and the 
torn surface, even in the adult, does not present a granular appearance. 
Hence, also, the stage of gray hepatization does not supervene so uni- 
formly and regularly, since there is less compression of the capillaries in 
the alveolar walls, and the mutual pressure of the inflammatory product is- 
less. In infants who have died with this form of pneumonitis, of six or 
eio-ht weeks' duration, it is not unusual to find the affected lobules still 
in the stage of red hepatization. Cell-proliferation occurs in the bron- 
chioles of the inflamed lung as in the alveoli, producing within them 
numerous plugs,' which, though they obstruct the entrance of air, are not 
so firm as in croupous pneumonitis, since they are destitute of fibrin. 

In favorable cases the lung affected by catarrhal inflammation returns 
to its normal state, probably by the same process as in croupous pneu- 



CHEESY PNEUMONITIS. 579 

monitis. In other cases, especially in scrofulous and feeble children, the 
inflammation, instead of resolving, passes into what is now designated 
cheesy, or by certain writers scrofulous, pneumonitis. 

Cheesy Pneumonitis. — Cheesy degeneration of the inflammatory pro- 
duct occasionally occurs in the croupous form of inflammation, but it is 
more common in the catarrhal. I have most frequently observed it in New 
York during epidemics of measles, when this form of pneumonitis super- 
vened upon the catarrhal bronchitis of that disease. Cheesy pneumonitis 
is in its nature chronic, and attended with great reduction of the vital 
powers. 

Cheesy degeneration of the exudate or infiltrate consists essentially in 
the absorption of the liquid portion, and fatty degeneration of the solid. 
The obstruction of the circulation in the capillaries and the accumulation 
of cells in the alveoli and bronchioles which cannot be expectorated, are 
conditions which favor the cheesy metamorphosis. The appearance and 
consistence of the lung when it has undergone this change are well ex- 
pressed by the term which is employed to designate it. The cheesy mass 
consists of fatty, shrivelled, and fragmentary cells, and amorphous mat- 
ter, in which can be traced the elastic fibres and larger vessels of the par- 
enchyma, the other histological elements having disappeared. 

The caseous mass after a time softens, attracting moisture from the 
surrounding tissues. The molecular detritus and the shrivelled cells are 
now suspended in a liquid, and, like any dead matter, they are irritant to 
the surrounding lung-substance. The bronchial tube which supplies the 
affected lobule, and which in many instances was the starting-point of 
the disease, again becomes pervious, either by softening of the plug or by 
ulceration at a higher point upon its walls, and air is admitted, which 
promotes the putrefactive process and chemical changes of the caseous 
substance. 

The lesion now described is that of pulmonary consumption, a disease 
not infrequent in children of two or three years. There are as yet no 
tubercles, but the presence of softening caseous material in the lungs very 
frequently leads to their development (see Art. Tuberculosis), and accord- 
ingly, before the case ends, clusters of tubercles may appear in the con- 
nective tissue and walls of the vessels of the lungs and in other organs. 

In the subsequent progress of cheesy pneumonitis, if the patient live 
sufficiently long, there occurs more or less expectoration of the offending 
substance, producing a cavity. Around the cavity a vascular pyogenic 
membrane forms, upon which granulations arise. These granulations, 
which produce pus abundantly, and from which small extravasations of 
blood are frequent, are gradually transformed into connective tissue. If 
the dead portion be expectorated, and there be a single small cavity, the 
child may recover, the empty space being finally filled up by the exten- 
sion of the granulations, and the production of a cicatrix, which contracts, 



580 PNEUMONITIS. 

producing a puckered appearance. Ordinarily, however, there are sev- 
eral centres of caseous degenerations, and several cavities resulting, which 
continue to enlarge by the progressive softening of the cheesy matter. 
Often, also, certain of the cavities intercommunicate. The bronchial 
glands undergo hyperplasia, and certain of them are apt, also, to become 
cheesy. As the disease advances, the suppuration and expectoration in- 
crease. The fatal result occurs sooner in children than in adults, and, 
therefore, the lesions, destructive and inflammatory, observed at autop- 
sies, are ordinarily not so far advanced in the former as in the latter. 
Other unfavorable changes may occur in the hepatized lung, but cheesy 
degeneration is the most common and noteworthy. 

Whether it is possible to inflate a lung which presents to the naked eye 
the appearance of pneumonitis, has long been regarded as a reliable sign 
of the presence or absence of inflammatory consolidation. The facts as 
regards the possibility of insufflation are these : In croupous pneumonitis, 
when it has passed beyond the first stage, insufflation is impossible in the 
lung of the child as well as adult, with the utmost force of the breath. 
We produce emphysema in healthy portions of the lungs, while the in- 
flamed area is not encroached upon. 

On the other hand, in catarrhal pneumonitis, which w r e have seen is the 
common form of pulmonary inflammation in children under the age of 
three years, and in which there is less distension of the air-cells by inflam- 
matory products, the lung can be inflated, except in protracted cases, but 
when fully inflated the solidified lobules can still be felt between the 
thumb and fingers. In protracted catarrhal pneumonitis, as well as in pro- 
tracted collapse, which, indeed, may and often does become a pneumoni- 
tis, full inflation is impossible. Central portions still remain impervious 
to air. While, therefore, the possibility or impossibility of inflating a 
lung removed from an adult, and which presents to the naked eye the apr 
pearance of pneumonic solidification, is a valuable sign as indicating 
whether or not the disease be pneumonitis, this test is uncertain and 
unreliable' when applied to the pulmonary lesions of children under the 
age of three years. 

Symptoms. — Croupous pneumonitis commonly begins abruptly, or it is 
preceded for a brief period by symptoms of a cold. In the adult, the 
abrupt commencement is ordinarily with a chill. In the child, there is 
often a sensation of chilliness, but a distinct chill is not common. Con- 
vulsions sometimes occur in place of a chill. Catarrhal pneumonitis, being 
ordinarily a secondary disease, begins in a more gradual way, its symp- 
toms being preceded by and associated with those of the primary affec- 
tion. 

The symptoms of acute pneumonitis, whether catarrhal or croupous, 
are the following : Anorexia, thirst, restlessness, elevation of temperature, 
acceleration of pulse according to the intensity of the inflammation and 



SYMPTOMS. 581 

the feebleness of the patient, flushed face, a countenance expressive of 
suffering, accelerated respiration, with an expiratory moan. These symp- 
toms are constant in the acute inflammation unless of the mildest form. 
Those which are important I shall explain more fully. 

The expiratory moan is described by writers as a pathognomonic symp- 
tom of this disease, or of pleurisy. It is evidently due to the pain ex- 
perienced from the movement of the inflamed part. As a rule, the expira- 
tory moan does indicate either pneumonitis or simple pleuritis ; but there 
are exceptions. It may occur, for example, from indigestible substances 
in the stomach and intestines, giving rise to acute dyspepsia ; or from 
certain forms of abdominal inflammation, which render movements of the 
diaphragm painful, as diaphragmatic peritonitis. 

The cough in the first days of pneumonitis is often dry or hacking and 
painful. It afterward, if the case be favorable, becomes looser, and is 
painless. We very seldom observe in the child the bloody sputum which 
characterizes pneumonitis in the adult, since in catarrhal inflammation 
there is much less exudation of blood-corpuscles. The sputum, which 
in this form of the disease is the product of secretion and cell-prolifera- 
tion, is at first thin and frothy, but afterward thicker and less tenacious 
from the increased number of cells. There is often, in the first period of 
the inflammation, pretty severe and constant headache, the patient com- 
plaining of the head, if old enough to speak, before he does of the chest. 
In a severe attack the child at this period lies with the eyes shut, appar- 
ently in a half-conscious state, fretful if spoken to or aroused, so that the 
physician might be led to suspect the presence of cerebral disease. If 
there be vomiting, accompanied with sudden twitching of the muscles, 
and convulsions — symptoms which sometimes occur — the liability to 
error in diagnosis is greatly increased. Cerebral symptoms are more 
prominent in the commencement of pneumonitis than subsequently. As 
the disease advances they subside, and symptoms referable to the chest 
become more conspicuous. 

The breathing is, as I have said, accelerated. Thirty or forty respira- 
tions per minute are common, and, in severe cases, the number reaches 
sixty or even eighty. In infants there is greater frequency of respiration 
than in children. In those at the breast, if the dyspnoea be urgent, nutri- 
tion is sometimes seriously interfered with, since in these severe cases 
respiration is performed more through the mouth than nostrils, so that if 
the infant seize the nipple, it is forced to relinquish it in order to breathe. 
Dilatation of the alse nasi, and depression of the infra-mammary region, 
accompany inspiration. The dyspnoea in catarrhal pneumoniti.s is often 
due in great part to accompanying bronchitis. 

The temperature in mild cases of pneumonitis is elevated to about 101° 
to 103° ; in severe cases it may reach 105° or even 107°, the former 
being the highest observed by Mr. Squire. In ninety-seven observations 



582 PNEUMONITIS. 

made by M. Roger, the average temperature was 104° during the active 
period of the inflammation. The face is therefore flushed, and the heat 
of surface pungent, except in weakly children, in whom, even in severe 
and active inflammation, the face is sometimes pallid, and the extremities 
i>f natural or less than natural temperature. 

The tongue is moist, and covered with a light fur ; the thirst is such 
that nutriment may be given in the form of drinks, when the loss of 
appetite prevents the use of solid food. The bowels are usually consti- 
pated. The secretions, in the first and second stages, are diminished. 
The urine is more deeply colored than in health, and in vigorous patients 
it deposits urates on cooling. The chlorides are also deficient or absent 
from the urine, so long as the inflammation is extending. 

In favorable cases, in from seven to ten days the heat and thirst de- 
cline ; the pulse and respiration gradually become less frequent ; the 
cough looser ; the features have a more placid or contented expression ; 
the appetite returns, and the patient is again amused by playthings. The 
improvement is progressive, but gradual. A slight cough is occasion- 
ally observed for two or three weeks after convalescence is fully estab- 
lished. 

Death in the acute stage of the inflammation commonly occurs from 
asthenia. The pulse gradually becomes more frequent and feeble, the 
respiration more oppressed, and finally, near the close of life, the face 
and extremities become cool. Occasionally death results from apnoea, 
due in great part to coexisting bronchitis. In exceptional instances it 
occurs from convulsions, followed by coma, especially in the first week. 
In those protracted cases in which the inflammatory products have under- 
gone cheesy degeneration death occurs from asthenia. 

Such are the symptoms and progress of ordinary acute pneumonitis in 
children. When the inflammatio n is subacute, as in those forms of the , 
disease which result from collapse or hypostasis, the symptoms are less 
pronounced. The respiration in such cases is but moderately accelerated, 
is attended by little pain, and therefore the expiratory moan is often ab- 
sent. An occasional short, dry cough occurs, with so little increase of 
temperature and quickening of the pulse that the pneumonitis is apt to be 
overlooked by the physician, the symptoms being referred to bronchitis. 
Pleuritis seldom occurs in connection with this form of pneumonitis, ex- 
cept when a small abscess or gangrene results in an affected lobule 
directly under the pleura. A few such cases I have observed. 

Tubercular pneumonitis extends over much or little of the lung accord- 
ing to the amount of tubercles. The symptoms are like those of severe 
primary pneumonitis, superadded to such as pertain to tuberculosis. 
This inflammation, when once established in the consumptive child, com- 
monly continues till the close of life. I have sometimes had these cases 
under observation for several consecutive weeks, even months, and during 



PHYSICAL SIGNS. 583 

the whole time there was not only acceleration of pulse and respiration, 
but the expiratory moan. As regards pneumonitis occurring in hooping- 
cough, it is an interesting fact that its symptoms modify those of the pri- 
mary disease, so that, during the active period of the inflammation, the 
paroxysmal cough diminishes, and a short, hacking cough and expiratory 
moan occur in place. As the inflammation abates, the spasmodic cough 
returns. Pneumonitis, occurring in measles, is more obstinate, protract- 
ed, and dangerous than the primary form. It. usually commences about 
the period of the decline of the eruption, and, in favorable cases, contin- 
ues two or three weeks. It is then a sequel, rather than complication. 

Physical Signs. — The physical signs of pneumonitis in infancy and 
childhood are the same as in the adult, but in a large proportion of cases 
they are less distinct. In a majority of patients under the age of three 
years the crepitant rale is not observed. This is due to the small size of 
the alveoli at this age. I have now and then detected it in quite young 
children, in whom it is a finer rale than in the adult. If observed, it is, 
of course, positive proof of the existence of pneumonitis. The physical 
signs, therefore, in the first stage of the inflammation, are often obscure 
in consequence of the absence of the pathognomonic rale. The vesicular 
murmur is somewhat intensified through the chest, and there is in this 
stage slight dulness on percussion over the seat of the inflammation due 
to engorgement of the vessels, but it is difficult to appreciate this. 

In the second stage, which supervenes more or less rapidly, the physi- 
cal signs are more distinct. Bronchial respiration is in most cases de- 
tected, higher in pitch than the vesicular murmur, with the sound of ex- 
piration higher than that of inspiration. The voice of the patient is 
transmitted to the ear applied over the seat of the disease, and often a 
peculiar vibratory sensation is communicated to the hand applied over the 
part, so that it is possible to locate the disease by palpation alone. There 
are frequently, in the second stage, and sometimes in the first, coarse 
mucous rales in various parts of the chest from coexisting bronchitis. 

Percussion, in the second stage, elicits a dull sound as compared with 
that produced on the opposite side of the chest. The dulness corresponds 
in extent with the solidification, and with the bronchial respiration. 

As the inflammation abates, the dulness on percussion gradually dimin- 
ishes, and the bronchial respiration is succeeded by the subcrepitant rale. 
Often, for a considerable period after convalescence is established, moist 
rales are observed in the chest, and sometimes the dulness on percussion 
•does not entirely disappear till after the health is fully restored. 

In catarrhal pneumonitis these signs are commonly less distinct than in 
the croupous form of inflammation. This is due in part to the limited 
extent of the inflammation, in part, in many cases, to its subacute charac- 
ter, and in part to the fact that it is apt to be double. When it results 
from hypostatic congestion it is nearly always bilateral. 



584 PNEUMONITIS. 

Diagnosis.— It will aid in diagnosis to recollect that under the age of 
three years, pneumonitis is ordinarily catarrhal, and that it is preceded 
by and associated with bronchitis. Coincident with, and often preced- 
ing its development for a few days, are the usual symptoms of nasal and 
bronchial catarrh. Defluxion from the nostrils, and other symptoms due 
to " taking cold," help us to diagnosticate catarrhal pneumonitis from 
the essential fevers, with the exception of measles. Croupous pneumo- 
nitis begins more abruptly, but in this form of inflammation the greater 
extent of pulmonary solidification soon gives us clear and unmistakable 
physical signs. The various forms of so-called remittent fever bear con- 
siderable resemblance as regards symptoms to certain cases of pneumonic 
inflammation, but in the latter there is more acceleration of respiration, 
and greater suffering, especially when the child is disturbed, than in the 
former. The physical signs, however, afford the decisive proof of the 
nature of the malady, as dulness on percussion, bronchial respiration of a 
higher pitch and harsher than the normal vesicular respiratory sound, 
bronchophony, vocal fremitus, etc. 

Difficulty sometimes attends the diagnosis of broncho-pneumonitis from 
simple bronchitis. The presence of the expiratory moan, if it be pretty 
constant and marked, affords evidence that the inflammation has extended 
to the lungs, but the physical signs constitute the reliable means of exact 
diagnosis. They should be carefully noted, in order to determine if there 
be some point of solidification. 

Solidification gives rise to dulness on percussion, bronchial respiration, 
and bronchophony. These three signs coexisting afford sufficient proof 
of pneumonitis, unless there be tubercular consolidation or possibly col- 
lapse supervening on suffocative bronchitis. The history of the case aids 
in determining whether there be either of these diseases. Moreover, col- 
lapse occurs later after the attack commences than hepatization, and does 
not produce so distinct bronchophony or bronchial respiration as is ob- 
served in ordinary cases of pneumonitis. 

Pleuritis with effusion may present physical signs which bear considera- 
ble resemblance to those in pneumonia ; but in pneumonia, except when 
associated with tubercular disease, the dulness on percussion is not so 
great as that from pleuritic effusion. In pleuritic effusion in a young 
child the respiratory murmur can often be heard with the ear applied over 
the liquid, but it is indistinct and transmitted through the liquid from a 
distance. The practised ear is able to discover the difference between it 
and the bronchial respiration of pneumonitis. Vocal fremitus, which is 
absent in pleuritic effusions, is another reliable sign of pneumonitis 
in children over the age of three or four years. In younger children it is 
indistinct. Occasionally the physical signs indicate the coexistence of 
the pulmonary and pleural inflammations. 

In catarrhal pneumonitis it is often difficult to determine certainly the 



PROGNOSIS — TREATMENT. 585 

nature of the disease, since the physical signs, if there be but little extent 
of inflammation, are absent or indistinct. I have often, in post-mortem 
examinations, found so small a part of the lung hepatized that it could 
not possibly have produced any appreciable dulness on percussion, bron- 
chial respiration, or bronchophony. Such cases are apt to pass for simple 
bronchitis, and, practically, this matters little, since the treatment required 
by the two is not dissimilar. 

Prognosis. — Primary pneumonitis, affecting only one lung, if properly 
treated, in most instances terminates favorably in children, and even in 
infants. If double, it is, as in the adult, much more serious, and in a 
large proportion of cases, fatal. Secondary pneumonitis, pneumonitis 
occurring in measles, hooping-cough, tuberculosis, or resulting from hypos- 
tatic congestion in the course of some exhausting disease, is, on the other 
hand, more frequently fatal. As death usually occurs from asthenia, the 
younger the child and more feeble the constitution, the greater the danger. 

Unfavorable symptoms are a pulse becoming more and more frequent 
and feeble, pallor of countenance, inability of the patient to support the 
head, total loss of appetite, refusal to notice or be amused by playthings, 
absence of tears when crying — a symptom which the French writers have 
pointed out — and the appearance of pemphigus on the face or elsewhere. 

Indications on which a favorable prognosis may be based are moderate 
acceleration of pulse, pneumonitis primary and limited to one side, ability 
to support the head or sit erect, being amused by playthings, etc. 

Treatment. — The treatment of the two forms of pneumonitis, namely, 
catarrhal and croupous, the former occurring chiefly under the age of 
three years, and being secondary, the latter occurring in most patients 
over that age, require to be considered separately as much as do their 
symptoms and anatomical characters. 

Catarrhal pneumonitis when developed from and upon a bronchitis, as 
it so often is, requires for the most part the continuance of the remedies 
which are appropriate for the primary disease. (See Art. Bronchitis.) 
But from the fact that it is secondary, and in children of a tender age, and 
since the danger as regards the pneumonitis is due to asthenia, more ac- 
tively sustaining measures are demanded than might be required for the 
uncomplicated bronchitis. When the pneumonitis has continued a few 
days, and often in its commencement, carbonate of ammonium and alco- 
holic stimulants are needed, and the diet from the first should be nutri- 
tious. An opiate, as the compound tincture of ipecacuanha, should be 
added to the cough-mixture, if there be restlessness or insufficient sleep, 
and the external treatment recommended for bronchitis should be contin- 
ued. In that form of catarrhal pneumonitis which is due to passive con- 
gestion or hypostasis, in the causation of which debility is an important 
factor, tonic and stimulating measures are still more imperatively re- 
quired. Frequent change of position is useful in such cases. 



586 PNEUMONITIS. 

In croupous pneumonitis, if seen at the commencement or within a few 
hours of the commencement, an emetic of ipecacuanha may be given, as 
recommended by Trousseau. This acts promptly as a cardiac sedative, 
diminishing somewhat the afflux of blood to the lungs, and moderating 
the inflammation. It should not be employed except at the period men- 
tioned. 

The abstraction of blood by leeches or otherwise has justly fallen into 
disrepute in the treatment of the inflammations of children, as it is too 
depressing. But while the application of leeches in catarrhal pneumonitis 
is very rarely admissible, on account of the tender age of the patient and 
the secondary character of the inflammation, they may be useful in robust 
children with croupous pneumonitis, if applied sufficiently early, namely, 
within the first twelve hours. Two leeches are sufficient for a child of 
five years. When solidification of the lung has occurred, the time for the 
abstraction of blood is past. But we have in aconite and veratrum viride 
efficient substitutes for bloodletting, which, by their sedative effect on the 
heart, diminish the exaggerated afflux of blood to the inflamed lung, and 
thus enable us to meet the indication of treatment in the first stage of the 
inflammation. It is important in all severe cases to preserve the blood 
and the strength, for the danger in the end is chiefly from asthenia. 
Aconite as a cardiac sedative in the treatment of children is safer than 
veratrum viride ; it is not necessary to watch its effects so carefully. 

The following will be found a useful formula for a child of five years : 

$. Tinct. ipecac, comp. (Squibb's), gtt. xxxij ; 
Tinct. rad. aconit., gtt. xvj ; 
Syr. bal. tolut. ; 
Aquae, aa § j. 
Dose, one teaspoonful every three hours ; or the aconite may be given alone, 
dropped in sweetened water or syrup of tolu. 

If bronchial respiration, bronchophony, and dulness on percussion are 
present, indicating the second stage ; in other words, if it appear from 
the signs that the inflamed lobe or lobes are hepatized, little benefit 
accrues from the further use of aconite or veratrum viride, and harm may 
result. In this stage the above prescription, with the aconite omitted, 
may be continued, or the following may be employed ; 

#. Morph. sulphat., gr. j ; 
Syr. ipecacuanhas, § ss ; 
Syr. bal. tolut., § iijss. Misce. 
Dose, one teaspoonful every three hours to a child of five years. 

The remarks made in reference to the use of quinia and digitalis for 
bronchitis apply with still more force to their use in both the catarrhal 
and croupous forms of pneumonitis. In secondary pneumonitis and pri- 
mary occurring in feeble children these agents are in many instances pre- 
ferable to any other medicine for the purpose of reducing the temperature 



TREATMENT. 587 

and pulse, since they produce this result without depression. They may 
be administered in these cases from the first day, and their use may obvi- 
ously be continued longer than would be safe for aconite or veratrum 
viride. 

From some observations recently made (1880-1881) in the New York 
Foundling Asylum, it seemed to us probable that quinine, given in one or 
two large doses at the commencement of acute primary pneumonitis, as 
five grains to a child of three years, exerted some controlling effect on the 
inflammation, perhaps even rendering it abortive, and that its subsequent 
use in smaller doses may yet supersede in great part that of aconite and 
veratrum viride. 

When the inflammation begins to abate there is usually progressive im- 
provement. Many now recover with simple mucilaginous drinks or mild 
expectorants for the accompanying bronchitis, as syrup of ipecacuanha or 
squills in small doses. Others require more sustaining measures, and for 
such carbonate of ammonium is preferable with, perhaps, quinia. In 
severe pneumonitis it is of the utmost importance to sustain the vital 
powers, even from the commencement of the inflammation. There can 
be no doubt that the great error in the therapeutic management of chil- 
dren with this malady has been the employment of medicines which re- 
duce the strength when gentler measures or those of a sustaining nature 
were needed. Alcoholic stimulants are required sooner or later in most 
cases, at an early period in feeble children and in secondary forms of the 
inflammation. Infants may take three or four drops of Bourbon whiskey 
or brandy for each month of their age every two or three hours. The 
diet should be nutritious, consisting of milk, animal broths, and the like, 
unless during the first three or four days in robust children. 

The bowels should be kept open, as an important part of the treatment 
of croupous pneumonitis in its first stages. A small dose of castor oil, 
Rochelle salts, or citrate of magnesium should be given if there be any ten- 
dency to constipation, and repeated from time to time if required. A 
saline aperient by its derivative and refrigerant effect in some cases obvi- 
ates the necessity of employing cardiac sedatives. A laxative enema is 
preferable for a feeble child, and in most cases of secondary pneumonitis. 

Local treatment is required in all cases ; counter irritation should be 
produced as soon as possible over the inflamed lobe, by mustard, iodine, 
or some stimulating liniment, and, except at the time of this application, 
the chest should be constantly covered with an emollient poultice, or with 
a cloth wrung out of warm water and covered with oil-silk. I prefer, 
however, the constant application, under the oil-silk, of the following 
poultice, made large but as thin as the cover of a book, and therefore 
light : 

B. Pulv. sinapis., fss ; 

Pulv. semin. lini, f viij. Misce. 



588 PLEURITIS. 

Vesication, in my opinion, very rarely expedites the cure or benefits 
the patient. The ordinary fly-blister should never be employed ; and if 
it be thought best to vesicate, cantharidal collodion should be prescribed 
for this purpose. A safe, almost painless, and at the same time efficient, 
mode of applying this, is in spots as large as a ten-cent piece, half a 
dozen, more or fewer according to the extent of the inflammation, the 
skin of course remaining sound between them. This mode of application 
obviates the danger of producing a troublesome sore, which sometimes 
occurs in children from the ordinary mode of vesication. 

In cheesy pneumonitis, which is always accompanied by anaemia, and 
great reduction of the vital powers, carbonate of ammonium with citrate of 
iron and ammonium equal parts, or cod-liver oil administered three times 
daily with two drops or more of syrup of iodide of iron, will be found 
useful, as is also quinine with iron. The patients require the most nutri- 
tious diet and alcoholic stimulants. In the local treatment of this form of 
inflammation vesication, even so mild as that by cantharidal collodion, 
should be avoided. 



CHAPTER VII. 

PLEUKITIS.* 

The term pleuritis or pleurisy is employed, in the following paper, to 
designate inflammation of the pleura, when not produced by extension of 
the inflammatory process from the lung, or by the irritation of tubercles 
upon or under the pleura. Catarrhal pneumonia, common in infancy ; 
croupous pneumonia, common in childhood ; and pulmonary tuberculosis, 
not rare in both periods in wasted and cachectic children, are ordinarily 
accompanied by pleurisy, arising consecutively to the lung disease, and 
limited nearly to the portion of the pleura which covers the affected lobes 
or lobules. But since in these cases the pleuritis is subordinate to and 
dependent on the graver diseases, and is comparatively unimportant, it does 
not require separate consideration. It is properly treated of in our books 
in connection with and as a part of those diseases. All other cases of 
pleuritic inflammation, although presenting wide differences in form and 
clinical history, are embraced under the general term pleuritis. 

Pleuritis : its frequency. — Pleuritis was formerly supposed to be rare 
in young children. Even M. Barrier, of Lyons, the author of a creditable 
treatise on diseases of children, wrote as late as 1860 : " Ainsi done, en 
generalisant les faits de Vallieux et les notres, nous pouvons dire : que la 
pleurisie, depuis la naissance jusqu'a 1'age de six ans environs, ne consti- 
tue presque jamais une affection simple, unique et independante de la 

* From the New York Obstetric Journal, 1880-1881. 



ITS FREQUENCY. 589 

pneumonie." But greater precision in the examination of cases, more 
accurate means of diagnosis, more knowledge of the nature of diseases, and 
more frequent autopsies have enabled the profession to correct this, as 
well as many other errors ; and it is now known that primary pleurisy is 
not infrequent in young children, even in infants. In asylums and hos- 
pitals for children, in which institutions the nature of diseases is more 
accurately ascertained than in private practice — for autopsies are made in 
the fatal cases — the frequency of pleurisy in its various forms : latent, 
sero-fibrinous, and purulent, is surprising to those whose knowledge of 
the disease has been acquired only through private practice. Thus, in 
the New York Foundling Asylum, in the seven months from April 1st to 
November 1st, 1879, while there were 35 cases of bronchitis, 21 of pneu- 
monia, and 3 of tuberculosis, there were 11 clearly ascertained cases of 
pleurisy. There can be no doubt that many cases of this malady in 
young children are mistaken by good practitioners for other diseases, 
especially for pneumonia, or if the pleurisy be to a certain extent latent, 
for remittent or malarial fever, or fever due to intestinal irritation. I 
have records of several cases occurring in family and hospital or asylum 
practice, in which children perished with a wrong diagnosis, or without 
diagnosis, when the post-mortem examination revealed pleurisy, some- 
times of long standing. Thus in one case of fatal empyema, commenc- 
ing at the age of six months, and continuing several months, chronic 
pneumonia had been diagnosticated by physicians known to be thorough 
in their examinations, and usually accurate. In another case, which 
proved fatal at about the age of one year, the child, who lived in a mala- 
rial locality, had been for weeks under treatment for supposed malarial 
disease ; but in this case diagnosis was easy, for at my first visit, which 
was when the child was dying, there was decided dulness on percussion 
over the right side of the chest. In this case, the right lung was adhe- 
rent to the ribs anteriorly and laterally, while posteriorly it was sepa- 
rated by pus, which crowded forward the organ, so that its posterior sur- 
face was concave. 

In the wards of the institutions and in the crowded quarters of the 
poor, pleurisy appears to be more frequent than in families in comforta- 
ble circumstances. Its frequency varies, also, in different years, accord- 
ing to the presence and prevalence of its causes. Thus, during epidemics 
of scarlet fever, it is more common than at other times. 

During several weeks immediately preceding May, 1874, when there 
was no unusual prevalence of the causes or conditions which give rise to 
pleurisy, I noted carefully the character of the sickness in 404 consecu- 
tive cases, under the age of twelve years, in private practice, and of 
these, two had primary pleurisy, or one half per cent. This is probably 
about the usual proportion of pleurisies in children in family practice, ex- 
cept when scarlet fever is prevalent. 



590 



PLEURITIS. 



I have preserved the records of 56 cases of pleurisy in children under 
the age of twelve years, most of them occurring in the institutions which 
I am attending, or have attended as physician, and the remainder in pri- 
vate practice. The statistics of these cases, embraced in the following 
table, are interesting, as showing the frequency of pleurisy, and pleurisy 
of the suppurative form, in young children. The large number of empy- 
emas seen in the table does not, however, indicate the true proportion of 
suppurative to sero-fibrinous pleurisies, since protracted and stubborn 
cases, which are largely empyemas, are more apt to be brought to the in- 
stitutions for treatment than are those of a milder and more manageable 
type. Thus, in the class of children's dis^„ r jS in the Bureau for the Re- 
lief of the Out-Door Poor, a large percentage of the cases are empyemas 
which have resisted treatment elsewhere. Besides, pleurisy with little 
exudation is sometimes latent or so mild that it is overlooked or not diag- 
nosticated, even by physicians who are thorough and careful in their ex- 
aminations, and I do not doubt that such cases have occurred in the in- 
stitutions and in my private practice during the time in which my statis- 
tics were collected. 



Age. 49 Cases. 



Under 2 


From 2 to 6 


From 6 to 


From 1 Yr. 


From 3 Yrs. 


Over 6 Yrs. 


Mos. 


Mos. 


12 Mos. 


to 3 Yrs. 


to 6 Yrs. 


3 ; all empy- 


15 ; nine at 


2 ; both em- 


13 ; eight 


10 ; seven 


6; five right, 


emas ; one 


least em- 


pyemas ; 


right, five 


right, 


one left, 


double. 


pyemas ; 


one right, 


left. 


three left. 


one em- 




seven on 


the other 


Exudation 


Exudation 


pyema. 




right 


left. 


in some 


m some 






side, four 




sero- 


sero- 






on left 




fibrinous ; 


fibrinous ; 






side, four 




in others 


in others 






double. 




purulent. 


purulent. 





Causes. — The common cause of primary pi euritis is the same as that of 
other idiopathic inflammations, namely, " taking cold." It is, there- 
fore, most common in times of changeable temperature. Cachexia is an 
acknowledged predisposing cause, so that children whose blood is impov- 
erished, whether from previous disease or from anti -hygienic influences, 
are more liable to this inflammation than those who possess a sound and 
vigorous constitution. From the operation of these two causes a larger 
proportion of cases occur among the children of the city poor than among 
those who are well nourished and who live in comfortable circumstances, 
since the cachectic and ill-cared for are not only more exposed, but are 
less able to resist noxious agencies. 

Pleurisy is not rare in new-born infants, and its cause, when thus oc- 
curring, is not always apparent. It may sometimes be heedless exposure 
to cold or to currents of air by the nurse, and sometimes cachexia, espe- 



CAUSES. 591 

cially when the inflammation is bilateral. The cause may perhaps some- 
times be derived from the mother, since septicaemia and puerperal fever 
are admitted causes. 

Billard, whose observations were made among foundlings in the Hospice 
des Enfants Trouves, says : " Pleurisy is more common among young in- 
fants than is generally supposed ; it often appears without the lungs par- 
ticipating in the inflammation. I have seen several infants die immedi- 
ately after birth from this affection." He relates two cases of double 
idiopathic pleuritis ending fatally at the ages of two and ten days (Dis- 
eases of Infants, page 419). Mignot, whose observations were made in 
the same institution, also records ten pleurisies, five of which were idio- 
pathic, in 119 dissections of new-born infants (Maladies pendant le Pre- 
mier Age). 

Cases like the following are not infrequent : 

In 1867, I made the post-mortem examination of a foundling who died 
in the New York Infant Asylum, at the age of about one month. On 
each side of the thorax, the pleura, costal and pulmonary, was uniformly 
injected, and a small amount of pus, not more than one drachm, was 
found in one pleural cavity, and a still less quantity of pus in the other, 
with little or no sero-fibrinous exudation. There was also pus at the root 
of each lung, lying not entirely upon the free surface of the pleura, but 
partly underneath it. 

The fact of a double pleurisy without disease of the lungs, which might 
produce it, indicated a constitutional cause, but the nature of this cause 
was obscure. 

One of the eruptive fevers, scarlatina, not infrequently produces pleu- 
ritis, occurring as complication or sequel. This result seems to be some- 
times due to the altered state of the blood, resulting from the presence of 
the scarlatinous virus. In other instances, it is probably the result of the 
retained urea, consequent on scarlatinous nephritis, for pleuritis is a com- 
mon complication of Bright' s disease, due, it is supposed, to the irritat- 
ing property of urea, which is excreted upon the pleural surface. Pleu- 
ritis, in young children, is sometimes also caused by the discharge into 
the pleural cavity of some morbid product, as pus, softened tubercle, or 
decomposed lung-tissue, which, from its highly irritating effect, causes 
intense and general inflammation of the pleura. I have observed several 
such cases. 

Thus, in November, 1866, an infant of three and a half months died of 
pleurisy, occurring upon the left side. The left lung was firmly bound 
down by adhesions, so as to be reduced to about one sixth its normal 
size. On attempting inflation of this organ, when it was removed from 
the body, air escaped from a small opening in the middle of the upper 
lobe, and around this opening the lung-substance was of a dark-reddish 
color, softened and disintegrated. It seemed probable from the ap- 



592 PLEURITIS. 

pearance that there had been hypostatic congestion, or perhaps pneumonia, 
in the posterior part of the lung, and that the loss of vitality and softening 
had occurred from the sluggish or suspended circulation in the part, and 
that the fatal pleurisy had resulted from a little of this decomposed 
tissue entering the pleural cavity. 

A case having apparently a similar origin occurred in the New York 
Foundling Asylum in October, 1879. 

An infant, aged five months and a half, became suddenly and severely 
sick with pleurisy on the right side, and died in five days. On opening 
the pleural cavity, air escaped. The record of the examination states : 
" In about the middle of the posterior surface of the lower lobe was an 
opening which admitted the tip of the little finger to the depth of one 
fourth to one third inch. The lung-tissue seemed to be disorganized, and 
of pultaceous consistence around the cavity. Through this cavity, which 
communicated with a bronchial tube, the air had escaped, which was no- 
ticed on opening the chest. 

Occasionally we meet cases, especially in foundling asylums, in which 
the cause is different from the foregoing, but in some respects similar. 
An indolent pneumonitis occurs over a circumscribed area in the posterior 
part of the lung, whether from hypostasis or exposure to cold. Minute 
abscesses occur in the inflamed parenchyma, not larger than pins' heads 
or small shot. Perhaps they are located in bronchioles, and are produced 
by the accumulation of muco-pus which collects in these tubes, and is 
not expectorated on account of the low vitality and feeble functional 
activity of the tissues concerned. These abscesses approaching the pleu- 
ral surface produce a circumscribed pleuritis of small extent ; and finally 
one, probably in some sudden movement of the lungs, as in crying or 
coughing, breaks into the pleural cavity, causing general purulent inflam- 
mation. The following was such a case : 

In May, 1859, a male infant, aged two months, was admitted into the 
Nursery and Child's Hospital. He was delicate, and had what was diag- 
nosticated a mild bronchial catarrh ; but by wet-nursing his general con- 
dition gradually improved. In July, however, he had repeated attacks of 
diarrhoea, and progressively lost flesh and strength. On August 3d his 
respiration became suddenly accelerated and painful, and death occurred 
from dyspnosa and exhaustion. No cough or other symptoms referable 
to the respiratory apparatus had been observed previously to the day of 
death. 

At the autopsy the intestines were found to present the usual lesions of 
intestinal catarrh of the summer season. The right lung was compressed 
by a sero-fibrinous exudation, though, from the small size of the pleural 
cavity, the quantity of exuded liquid was not more than two ounces. 
Nearly the entire right pleura, visceral and parietal, was covered with 
fibrin of a creamy appearance, and there were loose flocculi in depending 
portions of the cavity. This lung could be inflated, except a little of the 
lower lobe which was hepatized. The left lung also occupied a very small 
space, being partially collapsed. It could be readily inflated, when it ap- 



causes. 593 

peared normal, except a small portion in the posterior aspect of the lower 
lobe, which was partially covered with lymph, and was found to contain 
two abscesses, one closed and the other opening externally on the surface 
of the lung, and connecting internally with the bronchial tube. On at- 
tempting inflation, air passed directly through this opening. The closed 
abscess contained from one third to half a drachm of pus and disin- 
tegrated lung-tissue, as shown by the microscope. 

Another case showing a similar cause of pleurisy occurred in a female 
infant of about four months, in the same institution, in November, 1869. 

She was admitted in October, somewhat reduced from diarrhoea, but 
her health improved partially, though she remained feeble, and the 
records state that she was much troubled with meteorism and occasional 
pain. On November 2d, she was suddenly seized with great dyspnoea, 
and died in about fifteen minutes. No cough had been noticed or other 
symptom referable to the chest, but there can be little doubt that the 
occasional symptoms of pain, referred to in the notes, were due to the 
pleurisy. The body was much emaciated, and depending portions showed 
hypostatic congestion ; right lung adherent to diaphragm and to a consid- 
erable part of the costal pleura by fibrinous exudation ; this lung was 
somewhat compressed and non-crepitant ; its upper lobe floated in water, 
while its middle and lower lobes sank, and could be only partially in- 
flated ; this portion of the lung contained a few small superficial abscesses, 
each holding scarcely more than one drop of pus ; two of these were 
empty, and air passed through them on attempting inflation. They prob- 
ably one or both opened into the pleural cavity during life, but possibly 
they were opened in separating the adhesions which united the two pleu- 
ral surfaces at this point ; the pleural cavity contained from two to three 
ounces of liquid, consisting mainly of pus and fibrinous shreds. 

A similar case occurred in the New York Foundling Asylum, in Octo- 
ber, 1879. 

The patient, aged four months, began to be sick October 11th, having the 
characteristic symptoms, and died October loth. The right pleural cavity 
contained about 5"i of sero-purulent liquid, pressing the lung forward 
and toward the median line. In the posterior surface of the right lower 
lobe, near its base and immediately under the pleura, were three or 
four small abscesses, each not larger than a small drop of pus, and two 
or perhaps three of these had ruptured so that air escaped from them on 
attempting inflation, while one was closed, the pus in it being visible un- 
der the pleura. 

This cause of pleurisy, namely, the bursting of a minute abscess in the 
lung, and that in which a portion of the lung loses its vitality, disin- 
tegrates, and enters the pleural cavity, are probably rare, except in the first 
months of infancy in wasted and ill-conditioned infants, in families of the 
city poor and in the asylums. 

A peri-pharyngeal abscess, descending along the oesophagus, has been 
known to cause fatal pleuritis by bursting into the pleural cavity, and pus 
38 



594 PLEUEITIS. 

from carious vertebras has produced the same result. In January, 1864, 
I presented to the New York Pathological Society the lungs of an infant 
whose history was as follows : 

R., aged nine months, of strumous parentage, and whose only sister had 
suffered severely from strumous ophthalmia and periostitis, was taken sick 
about December 19, 1863, with febrile movement, attended by restless- 
ness, but apparently without any serious indisposition. On the 22d, the 
mother called my attention to a prominence just below the right clavicle, 
which proved to be an abscess, and a poultice was applied over it. On the 
24th, the prominence suddenly subsided, and immediately the symptoms 
were greatly aggravated. The pulse rose to 160 per minute, the respira- 
tion to from 60 to 80, and expiration was accompanied by a moan, indi- 
cating acute pleuritic or pulmonary inflammation. Within forty-eight 
hours after the disappearance of the swelling, and the exacerbation of 
symptoms, dulness on percussing over the right side of the chest was ob- 
served, and this increased till it was complete from the clavicle to the 
base of the thorax. The acceleration of pulse and respiration continued, 
the patient grew more and more feeble, and death occurred December 
31st. 

On dissecting away the integument from the right side of the chest, 
an abscess was opened, containing nearly one ounce of pus, located at 
the point where the tumor had been observed. At the base of this ab- 
scess, between two of the ribs, was a small, round opening, not much 
larger than a knitting-needle, leading directly into the cavity of the chest, 
so that on depressing the ribs liquid flowed back from the pleural cavity. 
On removing the sternum the liquid was found to be sero-fibrinous, with 
considerable pus in depending portions of the cavity. 

I have met one other, apparently almost identical case, occurring in an 
infant of seven months. 

Pleurisy in the adult is sometimes the result of violence. The most 
notable and unequivocal cases, having this origin, are those in which the 
ribs are fractured. It rarely happens that we can attribute the pleurisy of 
children to this cause. I can recollect only one case in which the inflam- 
mation seemed to be due to violence. 

In September, 1867, an infant of twenty-two' months, in the Almshouse 
on Blackwell's Island, having had a cough for half a year, and being some- 
what reduced, fell from bed, striking against the left side of the thorax. 
Severe pleuritic symptoms supervened, and the child died of empyema in 
three and a half weeks. More than a pint of pus was found in the left 
pleural cavity, pressing the heart beyond the median line, and the dia- 
phragm downward, so that it was convex toward the abdomen. The 
bronchial glands were hyperplastic and slightly cheesy, and a caseous no- 
dule lay in the anterior surface of the right lung, which seemed otherwise 
healthy. The left lung bound down by adhesions could be partially in- 
flated. Whether or not it contained small tubercles is not stated in the 
records. 

The occurrence of the injury just before the commencement of the 
pleurisy may indeed have been a coincidence, but the mother constantly 



ANATOMICAL CHARACTERS. 595 

believed that the fall caused the inflammation, and there was no other as- 
signable cause. 

It is probable, from the history of this case and the lesions, that the 
cheesy degenerations antedated the fall, and that the pleura was in an 
abnormal state and prone to inflammation when the injury was received. 

The etiology of pleurisy in children differs, therefore, from that in 
adults. Certain causes are the same ; but others, as scarlet fever, and 
irritating products generated in the system and bursting into the pleural 
cavity, are not rare in infancy and childhood, while they seldom occur in 
adults. 

Anatomical Characters. — In the commencement of pleuritis, the sub- 
pleural blood-vessels, lying in the connective tissue, and the capillaries of 
the pleura are engorged with blood, producing vascular points and arbor- 
escence, well seen through a magnifying-glass of low power. Frequently, 
in children as in adults, minute extravasations of blood, resulting from 
extreme congestion, occur under the endothelial layer, perhaps scarcely 
perceived by the naked eye, but readily seen under the glass. Immedi- 
ately exudation of liquid, holding numerous cells, begins in the connective 
tissue which surrounds the capillaries, the pleura becomes dry and lustre- 
less, while the production and exfoliation of its endothelial cells are 
greatly increased. These no longer present their normal appearance, but 
are swollen and granular, in consequence of the inflammation. 

Immediately after these parenchymatous changes occur, serum, fibrin- 
ogenic substance, and leucocytes begin to exude upon the free surface of 
the pleura. The term fibrinogenic substance, instead of fibrin, is em- 
ployed, because it is now believed that fibrin itself is not exuded, but a 
substance which becomes fibrin, through the presence and action of cer- 
tain agents with which it comes in contact, among which may be men- 
tioned air, red blood-corpuscles, and even serum, from which fibrin has 
been precipitated (Virchow, Cornil, Ranvier, and others). 

In the exuded liquid, even if it have the appearance to the naked eye 
of ordinary serum, the microscope always reveals the presence of pus-cells 
or leucocytes, and red blood-cells, however small their quantity may be. 
The minute rootlets of the lymphatic system, which are interspaces or 
lacunae in the sub-pleural connective tissue, and which, here and there, 
open by stomata upon the pleural surface, are clogged by inflammatory 
products, and their walls swollen at an early stage (E. Wagner and oth- 
ers). In these lymphatic channels, both pus-cells and coagulated fibrin 
are seen by the microscope. That pneumonitis, whether catarrhal or 
croupus, seldom occurs in superficial parts of the lungs without causing 
inflammation of that portion of the pleura which covers the affected 
lobules is universally known ; but the reverse is also true, that pleurisy 
seldom occurs without causing inflammation of the alveoli which are adja- 
cent to the inflamed membrane. The pneumonitis thus caused is so super- 



596 PLEURITIS. 

ficial that it is very liable to be overlooked at the post-mortem examina- 
tion, in the presence of the graver lesions of the plenra ; but a knowledge 
of its occurrence is important in diagnosis, for, though it may have no 
greater depth than a line, it is sufficient to produce crepitant rales, like 
those in ordinary pneumonitis. Therefore, if we hear these rales, we 
might mistake the disease for pulmonary inflammation and overlook the 
pleuritis — an error not unusual in the treatment of children. Trousseau, 
who surpassed most of his contemporaries as a clinical observer, wrote : 
" This sound, which is met with in the great majority of cases of pleu- 
risy, is in fact a crepitant rale, and I have called it the crepitant rale of 
pleurisy. My interpretation is very simple. Just as we never have ery- 
sipelas without engorgement of the cellular tissue, there cannot be erysip- 
elas of the pleura or pleurisy without an irritative engorgement of the sub- 
pleural cellular tissue or of the peripheric pulmonary parenchyma. This 
fluxion naturally carries with it into the pulmonary vesicles a serous exuda- 
tion. . . . We also meet with a fine sub-crepitant rale, which is 
very often heard quite at the beginning of pleurisy, and which likewise 
nearly always continues for some weeks. ' ' More recent observers and 
writers fully agree with the statement of Trousseau, except that what he 
designates irritative engorgement the microscope shows to be a true in- 
flammation of the pulmonary alveoli. 

There are four constituents of every pleuritic exudation, namely, serum, 
fibrin, red blood-corpuscles, and leucocytes or pus-cells, which last are 
identical, in appearance, with the white blood-corpuscles and the lymph- 
corpuscles, and the origin of which has been investigated by many micro- 
scopists. It is convenient to classify cases of pleuritis according to the 
quantity and relative proportion of these constituents as follows : 1st. The 
plastic, sometimes designated dry or adhesive. 2d. The sero-fibrinous. 
3d. The purulent. 4th. The hemorrhagic. In cases which pertain to 
the first group, the inflammation is chiefly parenchymatous, either no ex- 
udation occurring upon the free surface of the pleura, or if any, whether 
fibrin, pus, or serum, it is so slight that it possesses no clinical importance. 
The essential anatomical changes in this form of pleuritis, as regards the 
pleural surface, are rapid proliferation, retrogressive change, or decay and 
exfoliation of the endothelial cells, and the sprouting out of granulations 
which develop into connective tissue. In plastic pleuritis, there is no 
compression of the lungs, and the pleural surfaces are separated from each 
other only by the granulations which soon unite with those of the oppo- 
site surface. This form of pleuritis is not infrequently latent in children, 
for at the autopsies of those who have died of various diseases we often 
observe bands of connective tissue, uniting the opposite pleural surfaces, 
when the parents or nurses cannot recall to mind any sickness or symp- 
toms, such as pleuritis commonly causes. It is certain, also, that plastic 
pleuritis is often overlooked, when not latent ; the fever and other symp- 



PURULENT PLEUKITIS. 597 

toms being attributed to causes quite distinct from the true one. The 
symptoms and physical signs are obviously less pronounced in this than 
in other forms of pleuritis. 

2d. Sero-fibrinous Pleuritis. — This is the most frequent of all. It 
is the pleuritis which commonly results from catching cold. The serum 
exudes from the capillaries of the inflamed pleura in very variable quantity 
in different cases, and the pleural surface is soon covered with a fibrinous 
layer. This may be a mere film, or it may attain the thickness of half an 
inch or more. It is usually at first slightly attached, but afterward, from 
being blended with the granulations, it may be firmly adherent. In some 
cases it is quite compact, while in others it has a loose areolar texture, 
containing in its interstices serum and pus-cells. The fibrin is for the 
most part deposited on the pleura, but shreds and flakes of it also float 
in the serum. In the serum, as well as entangled in the fibrin, we find 
not only red blood-cells and leucocytes, but endothelial cells thrown off 
from the pleura which, as well as those still adherent, are almost always 
in the process of degeneration and decay. 

If a perpendicular section be made through the pleura, in this as well 
as in the other forms of pleuritis, many newly-formed cells, the lymph- 
corpuscles, are observed in the meshes of the sub-pleural connective tis- 
sue, and, as we examine the section nearer to the surface of the pleura, 
these cells are seen to be aggregated in masses, and held together by a 
structureless, homogeneous matrix. The lymph-corpuscles appear to be 
the active agents in the formation of granulations. They are observed in 
various stages of transformation, from the round to the spindle-shaped. 
The prolongations of the spindle-shaped cells unite with each other, so as 
to form the connective tissue, capillaries, and other elements of the gran- 
ulating surface. That the endothelial cells take no part in the production 
of the new tissue is inferred from the fact that most of them present the 
appearance of retrogressive change and decay. The granulations, as they 
sprout out from the pleura, become intimately blended with the fibrinous 
exudation, and when the effused liquid is absorbed, they unite with those 
of the opposite pleural surface, forming an organic union, by blood-ves- 
sels and nerves, between the lung and parietes, the lung and pericardium, 
or different lobes of the same lung, as the case may be. They pass, in 
two or three weeks, from embryonic to perfect tissue, vessels and nerves 
grow in them, and they possess, henceforth, all the properties of living 
tissues ; they are able to absorb ; they are liable to inflammation and 
haemorrhage, and may, in fine, participate in all the alterations of the 
organism of which they are a part (Jaccoud). 

3d. Purulent Pleuritis. — Although, as stated above, pus-cells are 
always present in the pleuritic exudation, we designate the disease puru- 
lent or empygema when the cells are so numerous as to render the liquid 
turbid. If there be a cloudiness, appreciable to the naked eye, and due 



598 PLEURITIS. 

to the pus-cells, the case is regarded as one of this form of pleuritis. 
Purulent pleuritis is, at first, in a large proportion of cases, sero-fibrinous, 
becoming purulent after some days or weeks — a fact readily ascertained 
by the use of the hypodermic syringe at different periods. In other in- 
stances, the pleuritis is purulent from the first. Pleuritis is, according 
to* my observations, more apt to be purulent in children than in adults, 
and in ill-conditioned children than in those who are robust. It is, 
therefore, apt to be purulent in one who has had an exhausting disease, as 
scarlet fever, and in the cachectic children, who reside in or are brought 
to the institutions for treatment. Thus, in the New York Foundling 
Asylum, in 1879, an infant, aged two months and three days, became 
feverish, and had the expiratory moan and hurried respiration characteris- 
tic of pleuritis. On the fourth day, Dr. Reynolds, who was in attend- 
ance, inserted the hypodermic syringe and filled it with thin pus. This 
was, apparently, a case of primary idiopathic empyaema. Pleuritis is 
purulent when it is produced by the entrance of some irritating substance 
into the pleural cavity, as pus or decomposed lung-tissue. 

The production of pus in the pleural cavity is often surprisingly rapid, 
for, when many ounces have been removed by the aspirator, nearly the 
original quantity is sometimes restored within two or three days. As 
Fraentzel says, it does not seem possible that so many pus-cells, which 
must surpass in number the aggregate of the white blood-corpuscles, could 
wander from the blood-vessels in so short a time, so that we must look 
for some other source of the immense production of leucocytes, in addi- 
tion to that discovered by Cohnheim. A large part of the pus-cells is, in 
all probability, produced by rapid segmentation of the lymph-corpuscles. 
In two cases of purulent pleuritis, both infants, I found pus underlying 
the pleura near the hilus, without apparently any loss of integrity in the 
pleura, in such quantity that it was immediately recognized by the naked 
eye. Pus under the pleura, as well as within the pleural cavity, was ap- 
parently due to unusual violence in the inflammation, and rapid produc- 
tion of leucocytes. 

Hemorrhagic Pleuritis. — This is not common. I recall but one case 
in a child, in whom the pleuritis occurred as a sequel of scarlet fever. 
The fluid several times removed by the aspirator had a deep reddish-brown 
color. I was apprehensive that the point of the aspirator, by wounding 
the granulations, had caused the haemorrhage which stained the pus re- 
moved at each subsequent operation. But, with the care exercised, and 
the great amount of blood-stained exudation, it seems almost certain that 
this was not the true explanation, and that it was a genuine case of 
haernorrhagic pleuritis. 

Haernorrhagic exudation in the pleuritis of children is sometimes due to 
purpura hemorrhagica, being, like the other haemorrhages, a symptom of 
the genera) disease. In other cases it signalizes the commencement of a 



HEMORRHAGIC PLEURITIS. 599 

new inflammation in the vascular granulations of a previous pleuritis. 
Occurring under such circumstances, it is due to the increased fluxion in 
the numerous delicate capillaries of the granulations. Pleuritis due to 
cancerous or tubercular formations in or upon the pleura is sometimes 
also hsemorrhagic. Jaccoud says : " A sero-fibrinous or purulent exuda- 
tion may be red by the transudation of hematin, without true haemorrhage 
; the red exudations, which have been observed in scorbutus 
and marsh cachexia are really due to these pseudo-haemorrhages." In 
those cases in which there is true haemorrhage, it is still uncertain 
whether rupture of the capillaries or a transudation ordinarily occurs, 01 
whether the blood-cells may not escape in both modes. 

A liquid pleuritic exudation, whether sero-fibrinous or purulent, obvi» 
ously produces an important mechanical effect from its location. It*. 
young children, especially those enfeebled by sickness, the expansive* 
power of the lung is slight, so that it readily yields to pressure applied to 
its surface, and becomes more and more compressed as the liquid accumu- 
lates. Except when retained by adhesions, the lung is pressed toward the 
mediastinum, and at the same time carried forward and upward. Pa- 
tients with pleuritis usually lie on the back and affected side, so that grav- 
itation determines to a considerable extent in what part of the pleural cav- 
ity the liquid will collect. In the considerable number of post-mortem 
examinations which I have witnessed of children who perished from pleu- 
ritis, chiefly empyasma, the lung was usually attached anteriorly to the 
thorax from the mediastinum outward, as far as the costo-chondral artic- 
ulations, or farther, except in the lower part of the cavity, where there 
were no adhesions, or adhesions only near the mediastinum. There were 
also attachments along the mediastinum, and attachments more or less 
firm on all sides, anteriorly, laterally, and posteriorly in the upper part of 
the pleural cavity, toward which the lung was compressed. Many varia- 
tions occur, depending on the amount of liquid and the extent of the ad- 
hesions, but judging from autopsies which I have seen, I would say that, 
in the average, in cases so severe that the question of operative interfer- 
ence arises, if we draw a line from the axilla downward and forward to 
the epigastrium, the lung is adherent to the thorax over the space anterior 
and internal to this line, while external and posterior to it the liquid sep- 
arates the lung from the ribs. This fact is important, as indicating the 
proper point for puncturing the chest, namely, below the lower angle of 
the scapula, and between the eighth and ninth ribs. One reason why the 
earlier performers of thoracentesis were so unsuccessful was that they 
selected the anterior wall of the chest as the point of operation. Nowa- 
days, however, no one would be justified in performing thoracentesis un- 
less he first employed the hypodermic syringe and removed fluid at the 
point which he selects for the puncture. The statistics of Mohr, relating 
to lung displacement in empyaema, chiefly statistics of adult cases, are 



600 PLEURITIS. 

somewhat different from my general recollection of cases occurring in in- 
fancy and childhood as stated above. In 23 cases he found the lung free 
from adhesions, and compressed against the vertebral column and the 
mediastinum ; in 13 cases the organ was compressed from below up- 
ward ; in 1 from above downward ; in 4 from within outward ; in 4 from 
behind forward, and in 4 from before backward. These variations de- 
pend on the adhesions which the lung happens to contract. Perhaps a 
point a little external to the perpendicular, passing through the angle of 
the scapula, is preferable for puncture, as I have known the lung to be 
adherent to the posterior wall of the chest near the mediastinum, when 
the portion farther removed, say two inches from the median line, was 
separated by interposed liquid. 

Sometimes the liquid is collected in multil ocular cavities formed by the 
connective tissue, and these frequently intercommunicate. Exceptionally 
in children, as in the adult cases observed by Mohr, when there has been 
a large and rapid liquid exudation, or when the disease has been violent 
and of short duration, there are no adhesions. 

On account of the great difference in the size of the pleural cavity at 
different ages during infancy and childhood, the amount of liquid, which 
produces that degree of compression of the lung which materially impairs 
its function, varies greatly. At the age of four months, three ounces 
produce complete collapse of lung, so that it resembles a fleshy mass 
(carnification). The largest amount of liquid relatively to the size of the 
chest, in any of the cases which I have observed, was about one and one 
half pints, in the left pleural cavity in an infant that died at the age of 
twenty-two months, in September, 1867. The heart lay chiefly to the 
right of the median line, and the diaphragm was convex toward the 
abdominal cavity. The case occurred in the Almshouse on Blackwell's 
Island, and might in all probability have been relieved, had attention been 
directed to it sufficiently early. 

Liquid in the left pleural cavity, when considerable, presses the heart 
toward the mediastinum, so that the apex beat, instead of being a little 
internal to the linea raamrnalis, approaches the sternum. As the heart is 
carried to the right, the beat is felt under the lower end of the sternum, 
and with still greater increase in the effusion, the pulsation is detected 
by the finger, to the right of the sternum. If the exudation be on the 
right side, the displacement of the heart toward the left is, for obvious 
reasons, less than the displacement toward the right, in pleuritis of 
the left side. Much external pressure upon the heart embarrasses its- 
movements, and prevents proper filling of its cavities, while the action 
of the organ is accelerated so as to compensate. Therefore, the pulse is 
quick and feeble. 

In one instance in my practice, the lower extremities, and the portion 
of the trunk below the thorax, became cedematous, from compression of 



HEMORRHAGIC PLEURITIS. 601 

the ascending vena cava, and writers allude to cases in which other vessels- 
and ducts, as the thoracic, are compressed, so as to seriously embarrass 
their functions. The patient with the oedema was a boy of about four 
years, with empyaema of the left side. 

In large effusion, the mediastinum is pressed against the healthy lung 
so as to diminish its transverse diameter, and Traube has shown that the 
effect of this is to increase the length of the lung, or its vertical measure- 
ment. Consequently as the lung on the healthy side extends lower than 
in the normal state, the convexity of the diaphragm on this side is dimin- 
ished, as well as on the affected side, where it is depressed by the effu- 
sion. 

The pleura in protracted cases of empyaema becomes much infiltrated, 
and from the growth of connective tissue which blends with it, is thick- 
ened, sometimes to the extent of one or two lines. A few months since, 
in removing the lungs from the body of a young infant that perished of 
empyaema in the N. Y. Foundling Asylum, a portion of the costal pleura, 
two or three inches in diameter, being adherent to the lungs, was detached 
from the ribs. It had a thickness of fully two lines, and its free surface 
was rough. 

Occasionally the inflammation extends from the pleura to the pericar- 
dium, producing general pericarditis. I recall to mind four cases with 
this complication, in which the diagnosis was verified by post-mortem ex- 
aminations. All had empyaema, three on the left, and one on the right 
side. Pericarditis, always a grave disease, is almost necessarily fatal, 
when thus occurring as a complication of empyaema. More rarely the 
inflammation extends from the pleura to the peritoneum. One such case 
occurred in my practice, the child dying of empyaema of the right side, 
and at the autopsy we found the lesions of a localized diaphragmatic peri- 
tonitis of the right side, with a fibrinous exudation of small extent on the 
convex surface of the liver, directly opposite to that on the diaphragm. 
"We are indebted to Von Recklinghausen for knowledge of the mode in 
which inflammation is propagated from the pleura to the peritoneum, and 
the same explanation probably applies to its propagation to the pericar- 
dium. In the serous covering of the diaphragm, pleural and peritoneal, 
minute stomata have been discovered, which pertain to the lymphatic sys- 
tem. They open upon the surface of the diaphragm, and underneath in 
the substance of the diaphragm connect with lacunae or interspaces, from 
which the minute lymphatic vessels originate. These stomata and lymphatic 
spaces, pervious in their normal state, are usually clogged, as has been 
stated above, by inflammatory products, when the serous membrane is in- 
flamed. Occasionally the inflammation traverses these lymphatic chan- 
nels from one surface to the other, from the pleura to the peritoneum, 
thus causing by extension a circumscribed peritonitis. 

The changes which the inflammatory products undergo are the follow- 



602 PLEUKITIS. 

ing : With the abatement of the inflammation, the liquid portion begins 
to be absorbed, though absorption is much more tardy than in non- 
inflammatory effusions, since the absorbents are to a great extent covered, 
and clogged by fibrin and pus. The serum is first absorbed, and the floc- 
culi of fibrin sink into depending portions of the cavity, or become at- 
tached to the fibrinous layers or the granulations upon the pleural surface. 
The pus-cells and the fibrin, whether in flocculi or layers, begin to un- 
dergo retrogressive change. They become granular from fatty degenera- 
tion, liquefy, and are absorbed. Sometimes portions of these degen- 
erated products, which are not absorbed, form inert caseous masses, in 
recesses of the cavity, or between the bands of connective tissue, where 
they remain unchanged for years. With few exceptions, those who 
recover from an attack of pleuritis experience no subsequent ill-effect, 
though the bands and patches of connective tissue are permanent. 

Pus always possesses irritating properties. Decomposed and putrid 
pus (ichor) is very irritating. Empysemic pus, therefore, like pus in 
other situations, now and then produces ulceration or necrosis of the pleu- 
ral surface, by which it is confined, and in consequence of its destructive 
action, it sometimes establishes an outlet by which it escapes, with relief 
of the patient and cure of the disease. The chest wall is thinnest anteri- 
orly, in the infra-mammary region, and at this point the pus, when it 
makes its way through the thoracic wall, usually points and discharges. 
The fistulous opening thus produced continues many months, until the 
pleural cavity is gradually obliterated by the adhesions, and the patient 
recovers. 

By a similar destructive process in the pulmonary pleura, pus occasion- 
ally escapes into the bronchioles, and is expectorated. This mode of cure 
appears to be common in children, for my attention has not infrequently 
been called to the fact that children, during the progressive but slow con- 
valescence from empysema, expectorated large quantities of muco-pus, 
although in some of the cases pus had been removed by the aspirator or 
trocar. Fraentzel makes the remark, which is fully sustained by clinical 
experience in this country, that although an opening is made in the lung 
by the necrotic or ulcerative process, so that pus escapes into the bronchi- 
oles, air does not pass from them into the pleural cavity. Pyopneumo- 
thorax is very rare in the empysema of children, except as air is admitted 
in the operation of thoracentesis. 

As the liquid is absorbed, the compressed lung ordinarily expands in 
proportion to the absorption, so that more and more air enters its alve- 
oli. But frequently, in cases of long duration, the absorption proceeds 
faster than the expansion, so that the ribs on the affected side sink below 
their normal level. As a consequence, the inter-costal spaces are nar- 
rowed, the shoulder is depressed, and the dorsal portion of the spinal col- 
umn bends to accommodate the ribs so as to be concave toward the 



SYMPTOMS. 603 

affected side. It is very rarely that the deformity thus produced is per- 
manent. Though the newly formed bands and patches of connective tis- 
sue may so bind the lung that its return to the normal state is tardy, yet, 
with few exceptions, the alveoli one after another open to admit air, and 
when full inflation is attained, the symmetry of the chest is restored. 
But there are rare cases in which the newly formed connective tissue is 
firm and unyielding, almost as cartilage, and lime salts are sometimes de- 
posited in it, forming a calcareous plaque, which invests the lung like a 
cuirass. An unexpanded lung, with such a covering, obviously can never 
afterward be fully inflated. I can recall to mind, however, only one case 
of permanent complete collapse or carnification of lung, resulting from 
pleurisy. The inflammation, which was treated by the late Dr. Cam- 
mann, occurred in childhood, and several years afterward, when the 
patient reached womanhood, although the general health was good, there 
were physical signs of an unaerated lung, and the consequent deformity 
(depressed shoulder and ribs, and bent spinal column). Pleurisy with its 
granulations and retrogressive products affords one of the conditions in 
which tubercles are developed, so that we sometimes find at the post-mor- 
tem examination of cases which have been protracted, " miliary tubercles 
in the pleura, while chronic phthisis and general tuberculosis are absent" 
(Delafield). 

From the intimate relation of the heart to the lungs, this organ obvi- 
ously suffers severely in every large pleuritic exudation. Total compres- 
sion of a lung arrests one half of the circulation through the pulmonary 
artery, except as the increased flow in the opposite lung serves for com- 
pensation. Hence, in cases of large effusion, which end fatally, we com- 
monly find the pulmonary artery and the right cavities of the heart dis- 
tended with blood and clots, while the left cavities, having received a 
diminished quantity of blood, are probably empty. 

Symptoms. — As has been stated above, pleuritis in children is some- 
times latent, or attended by symptoms so mild as to attract little atten- 
tion, even when there has been general inflammation of the pleural sur- 
face with much effusion. Both primary and secondary pleuritis may pre- 
sent this form, latency being more frequent the younger the patient. In 
feeble, cachectic children, with blood thin and impoverished, pleuritic 
symptoms, as pain, dyspnoea, and fever, are less pronounced than in the 
robust, and, hence, latency is more common in the tenement-house popu- 
lation of the cities and in the institutions than in the better walks of life. 
The following is a not infrequent example of latency. A feeble infant, 
aged five months and twenty-eight days, died suddenly in the Nursery 
and Child's Hospital, in December, 1870. The attention of the resident 
physician had not been called to it, as it was not supposed to be sick, ex- 
cept that it was ill-nourished and its general condition bad. The nurse 
who had charge of the ward stated that it presented no symptom of acute 



604 PLEURITIS. 

disease, unless a slight cough during the three or four days preceding its 
death. Percussion over the right side of the chest of the corpse gave a 
flat resonance, and at the autopsy the right lung was found compressed, 
nearly or quite destitute of air, and covered by a loose fibrinous layer, 
three fourths of an inch thick in places, and a moderate serous exuda- 
tion. 

Ordinarily acute idiopathic pleuritis in children begins quite abruptly, 
and with symptoms which attract attention from the first. Probably in 
most instances it is preceded by rigors, or a chilly sensation, but this 
usually escapes notice, if it be present, in patients under the age of five 
or six years. Fever, fretfulness, and a physiognomy indicative of pain 
are the common initial symptoms. If the patient be an infant, the 
fretfulness closely resembles that produced by colic, for which I have on 
several occasions known it to be mistaken by the attending physicians. 

The symptoms of pleuritis are twofold, namely, the constitutional, or 
such as are common to all inflammations, and the local, or those refer- 
able to the chest. Various observers have noted the position in which 
patients lie in bed, as indicating the seat of the inflammation. It has 
been stated that adults, in the commencement of pleuritis, ordinarily ob- 
tain most relief with a decubitus on the sound side, but, when effusion 
has occurred, they lie on the affected side, unless there be marked dysp- 
noea, which is most relieved by a semi-erect position, which allows 
greater descent of the diaphragm. I have not noticed that children with 
pleuritis prefer any fixed or uniform position, except there be marked dysp- 
noea, which may prompt them to elevate the shoulders. The patient 
in the acute stage is commonly quiet when he lies in the position which 
he selects, and if disturbed from it becomes more fretful, his cough more 
frequent, and his suffering apparently increased. 

In ordinary cases, the temperature rises on the first day to 1 02° or 
103°. If it be more elevated than this, there is apt to be a complica- 
tion. The fever begins to abate when the exudation has occurred. In 
suppurative pleuritis, the febrile movement is more protracted, often con- 
tinuing for weeks or months, presenting, after the acute stage has passed, 
the characters of hectic fever with morning abatement and evening recru- 
descence. In weakly and anaemic children, even when the pleuritis is 
pretty severe, and most of the usual symptoms are present, the tempera- 
ture may be but slightly elevated. Thus, in one of the institutions with 
which I am connected, a young infant, whose fretfulness was during the 
first twenty-four hours ascribed to colic, the axillary temperature during 
the first three days never rose above 100°. 

The pulse, in a quiet state, is usually between 105° and 120°, but in 
young children who are restless it is often more frequent than this, dur- 
ing the first three or four days. It is accelerated as long as the tempera- 
ture is elevated, but in sero- fibrinous pleuritis, after exudation has 



SYMPTOMS. 605 

occurred, its frequency diminishes unless the heart be compressed. Com- 
pression and imperfect or partial filling of the cavities of the heart pro- 
duce a feeble and rapid pulse. In empyema the pulse is accelerated as 
long as pus is confined in the pleural cavity, unless its quantity be small. 

Headache, usually frontal, is frequent during the febrile stage. Con- 
vulsions, which occasionally occur in the beginning of pneumonitis, are 
rare. Pain in the chest, on the affected side, is common, and is, there- 
fore, a valuable diagnostic symptom, but it is often slight, and apt to be 
overlooked in infants and feeble children. It is increased by movements 
of the chest- walls, as in full inspiration, by coughing, or when pressure is 
made by the fingers in the examination. Its common seat is between the 
fifth and eighth ribs, external to the linea mammalis, but there are many 
cases in which the pain is referred to some other part, as the infra-clavi- 
cular, mammary, infra-mammary, or even the scapular or infra- scapular 
region. Rarely, it is referred to the epigastric or umbilical region, or 
even, it is said, to some point upon the sound side of the thorax. This 
location of the pain at a point distant from the seat of the inflammation 
is attributable to the anastomosis of the intercostal nerves with those of 
the opposite side of the chest, or with those which ramify in the abdomi- 
nal walls. 

The pain of pleuritis, as it ordinarily occurs, has received different ex- 
planations. It has been attributed to tension of the pleura, to friction of 
the pleural surfaces on each other, and to extension of the inflammation to 
the neurilemma of the minute nervous branches of the pleura. All these 
causes apparently act in producing it, but the persistent pain in the first 
days of pleuritis, though increased by motion, is probably due in great 
part to that last mentioned. Pleuritic pain is sharp or stitch-like. It be- 
gins to abate in a few days, and in a large proportion of cases ceases by 
the fifth or sixth day; it is no longer noticed, except in coughing or dur- 
ing sudden movement of the chest. 

The respiration is accelerated, as in all febrile diseases, but it is more 
rapid than in inflammatory ailments, which do not involve the thoracic 
organs, on account of the pain experienced on full inspiration. The 
patient instinctively avoids full inflation of the lungs, and the breathing is 
consequently rapid, to compensate for incompleteness of the inspiratory act. 

In ordinary attacks of pleuritis, painful and hurried respiration is of 
short duration. It becomes easier and more natural toward the close of 
the first week. In subacute and chronic cases, the rhythm and frequency 
of respiration differ but little from the normal. 

A cough, whatever the form of pleuritis, is one of the earliest symp- 
toms. It is short, frequent, and dry, and in the most favorable cases be- 
gins to diminish in the second week. A loose cough is due to accom- 
panying bronchitis, or broncho-pneumonitis, or, at a late stage of the dis- 
ease, to escape of pus from the pleural cavity into the bronchial tubes. 



606 PLEUKITIS. 

Little need be said in regard to symptoms referable to the digestive ap- 
paratus. Vomiting is common on the first and second days. Thirst, loss 
of appetite, and consequent loss of flesh and strength, are uniformly pres- 
ent. In empysema, which, from its nature, is protracted, nutrition is 
always greatly impaired. The surface presents an anaemic appearance, 
the flesh is soft and flabby, and the emaciation is progressive till the pus 
is evacuated. 

Physical Signs. — In children above the age of three or four years, the 
physical signs differ but little from those in adult cases, but under this 
age there are certain differences which the practitioner should know. We 
may, in the commencement of the attack, notice diminution in the move- 
ment of the chest- walls on the affected side, since the patient instinc- 
tively endeavors to repress respiration on that side, in order to lessen the 
pain. In severe cases, the epigastrium and hypochondria are sometimes 
depressed during inspiration (the so-called abdominal respiration), but this 
sign is less common and less marked than in severe bronchitis, and when 
present it may be largely due to accompanying bronchitis. After effusion 
has occurred, and the pain has abated or is slight, the signs due to irregu- 
lar respiration are less pronounced than at first. The breathing is now 
nearly or quite normal ; but it is well known that the effusion, if consid- 
erable, is apt to cause fulness or bulging of the thorax on the affected side, 
which is appreciable to the sight, so that its circumference on measure- 
ment is found to be greater than in health. But inequality of the two 
sides produced by the liquid is more common in children of an advanced 
age than in those under the age of three or four years. In infants, even 
when there is a large liquid exudation, the bulging is often so slight that 
it is scarcely appreciable, either by sight or measurement, and in not a 
few there is no apparent difference in the circumference of the two sides. 
I have repeatedly made careful measurements in infantile pleuritis during 
the stage of effusion, and been unable to convince myself that there was 
any difference, although other signs indicated the presence of an effusion 
which filled at least one half the pleural cavity. I explain this fact in this 
way. The lungs of an infant, especially of one reduced by sickness, are 
very liable to a state of semi-collapse or partial inflation in their whole 
extent, and of complete collapse of their thin borders, as of the tongue-like 
process of the left upper lobe, which lies over the pericardium and of 
the margins of the lower lobes, which lie in the angle made by the 
thorax and diaphragm. This occurs in the weakly infant, even when 
there is no obstruction to the entrance of air, and the liability to it is 
greatly increased by external pressure applied to the lung, as from a pleu- 
ritic effusion, so that the lung recedes, becomes compressed, and un- 
aerated, before the ribs yield to the pressure. If the exudation cease as 
soon as the lung is collapsed, there is little or no outward displacement of 
the ribs, and the intercostal spaces are not elevated. It is obviously very 



PALPATION — PERCUSSION. 607 

important to know this difference between infantile and adult cases, as it 
has a bearing upon the diagnosis between pleuritis with effusion and 
pneumonitis. 

Palpation. — In adults, and in children with strong voices, if the lung, 
deprived of air either by compression or an exudation within its alveoli, 
lie against the chest-wall, speaking or moaning produces a vibratory sen- 
sation which is communicated to the hand placed upon the chest. The 
fremitus is feeble or not appreciable when the voice is feeble. Therefore, 
in infants whose vocal cords are small, and particularly in infants reduced 
by sickness, this sign is ordinarily absent, or so slight that it is detected 
with difficulty, while in older and robust children it is distinctly per- 
ceived. If the conditions be otherwise favorable for the production of 
fremitus, but the lung be pressed away from the ribs by an intervening 
liquid, no vibration is felt when the patient speaks or cries. But if, in 
the same case, the fingers be removed to the supra-scapular, axillary, in- 
fra-clavicular, or mammary region, where the compressed lung comes in 
contact with the walls of the chest, fremitus may be perceived. Palpa- 
tion also enables us to ascertain the point of apex-beat of the heart, varia- 
tion of which from the normal site being one of the most conclusive 
proofs of a pleuritic effusion. 

Percussion. — In the first hours of pleuritis, there is either no percepti- 
ble change in the percussion sound, or the resonance is slightly dimin- 
ished, from the fact that inspiration on the affected side is resisted by 
the patient, and the lung is only partially inflated. When exudation oc- 
curs, if there be a thin layer of liquid over the lung, the percussion 
sound is tympanitic. It has, therefore, this quality at an early stage in 
the infra-mammary, mammary, and perhaps infra-scapular regions, when 
the amount of liquid is small, and at a later stage, when the quantity of 
liquid is greater, the percussion sound over the lower part of the chest is 
dull, while that over the central or upper part is tympanitic. Entire fill- 
ing of the pleural cavity with liquid, and total exclusion of air from the 
lung, give rise to a dull or flat percussion sound over every part, from the 
apex to the base. It may be stated as a rule in the pleuritis of children 
that, at a certain stage of the effusion, percussion produces a sound which 
is either decidedly tympanitic or which partakes of the tympanitic char- 
acter. Skoda attributed the occurrence of tympanism to the fact that a 
lung still aerated vibrates better if surrounded by a thin layer of liquid, 
and consequently gives better resonance than when it lies against the 
chest- walls. 

When the exudation is so great that the lung is totally compressed, 
and removed to a distance from the chest-walls, the finger in percussing 
experiences a sensation of solidity or resistance, and there is no longer 
any vibration of the ribs. Consequently the percussion sound is dull or 
flat, as over any solid body, differing from that in pneumonitis, in which 



608 PLEURITIS. 

there is still some vibration of the chest- walls, and the dulness is not ab- 
solute. In pleuritis, therefore, there is, according to the amount of exu- 
dation, either nearly the normal percussion sound, as at the beginning of 
the attack and in any stage of plastic pleurisy (pleuresie seche), or a zone 
of dull sound below, and another of tympanitic sound above, or a zone of 
normal resonance above, and one of dull resonance at the base, with an 
intervening one of tympanism, or, finally, there is absolute dulness from 
the clavicle to the base of the chest. 

It very rarely happens in the child that the level of the fluid changes 
by changing the position, on account of the adhesions, so that this sign, 
described in the books as one of great importance in diagnosis, affords 
very little assistance in case of children. 

Auscultation. — In the beginning of pleuritis, auscultation affords but 
slight information, except that the practised ear may detect a little dimi- 
nution in the fulness of the respiratory act in the lung, whose pleura is 
inflamed, and perhaps a slightly exaggerated respiration in the other 
lung. But after twelve or fifteen hours, when exudation begins to occur 
upon the pleural surface, we may hear the dry friction sound, which can 
be imitated by pushing the finger strongly across the dry palm of the 
hand. It is only heard in occasional cases, since the physician may not 
make his visit at the proper time for hearing it, or he does not apply the 
ear over the proper place. Fraentzel says : ' ' We shall scarcely ever fail to 
find the friction sound, in recent pleuritis, if we look for it early and dili- 
gently in some circumscribed spot." I do not think that this remark, 
however true it may be of adult cases, is entirely correct as regards chil- 
dren, for it is only in exceptional instances that it can be heard in them. 
It occurs both during inspiration and expiration, and it does not disap- 
pear after coughing. Being produced upon the surface of the lung, it 
seems near the ear of the auscultator. Perhaps it is not observed during 
several consecutive respirations, and then a deeper inspiration causes the 
pleural surfaces to glide upon each other, and it is detected. The 
friction sound as sometimes heard is well expressed by the term scraping, 
and in other cases by the term creaking, as was noticed by Hippocrates, 
who compared it to the creaking of leather. 

In some patients it is heard for a brief period and does not recur, and 
it may be detected only during strong and deep respiration or in cough- 
ing. It disappears entirely when the accumulation of liquid prevents con- 
tact of the surfaces. After absorption of the liquid, the friction sound 
may reappear, and in certain patients it is heard only at this time, namely, 
in the third stage. 

An interesting and common sound heard on inspiration is the so-called 
crepitant rale of pleurisy, produced in the superficial alveoli. The re- 
marks made by Trousseau upon it have been already given. As stated 
above, the inflammation extends from the pleura to the pulmonary vesicles 



AUSCULTATION. 609 

which lie directly underneath, and as soon as exudation occurs within 
them, the anatomical conditions are present in which the crepitant rale 
is produced, as in the ordinary form of pneumonitis. This rale may ob- 
viously be heard before any effusion takes place upon the free surface of 
the pleura, and it continues until the alveoli are so compressed by the 
pleuritic exudation that they no longer admit air. 

The exudation in the pleural cavity changes the character of the respi- 
ratory sound. A thin layer of liquid over the lung causes diminution in 
the force of the vesicular murmur, and soon an expiratory as well as an 
inspiratory sound begins to be heard. This modified vesicular mur- 
mur is weak, and more distant from the ear than the respiratory 
sound of health. When the exudation is sufficient to close the 
alveoli, while the air still traverses the medium-sized bronchial tubes, we 
notice a tubular or bronchial bruit. If the small and medium-sized tubes 
are compressed, while the air enters the large tubes, the respiratory bruit 
may be amphoric. Total absence of respiratory sound results from com- 
plete collapse of the alveoli, and consequent exclusion of air from them, 
and arrest of the movements of the air in the tubes of the affected side. 
Jaccoud says : " Regarded as a sign of the quantity of the effusion, the 
modifications of the respiratory bruit, and of the respiration, may then be 
arranged, in an increasing series as follows : diminution of the vesicular 
murmur ; feeble respiration {souffle doux) ; no sound, and feeble respira- 
tion ; bronchial respiration ; no sound, and bronchial respiration ; no 
sound, and cavernous respiration ; general absence of sound (silence 
general). The replacement of an inferior term of the series by a superior 
term implies an augmentation in the quantity of liquid, and in general 
the passage of a superior term to an inferior term denotes a diminution of 
the effusion." But this statement relating to the effect upon the auscu- 
latory sounds of the increase and decrease of the liquid must be modified 
as regards patients under the age of five years. In such patients it is 
rare, however great the effusion, that respiration is not heard when the 
ear is placed over the liquid. This is due to the small size of the pleural 
cavity, and the consequent ready transmission of sound from the centre 
of the thorax to its periphery. According to the amount of exudation 
and the degree of compression, the respiratory sound is a faint and dis- 
tant vesicular, or broncho-vesicular, or bronchial murmur, and its charac- 
ter is found to vary from one to the other of these sounds, as we apply 
the ear over different parts of the chest. 

When the inflammation is active, and the exudation occurs rapidly, 
bronchial respiration may be heard as early as the second or third day, or 
even by the close of the first day, in the infra-scapular region. If, on 
the other hand, the inflammation be chiefly plastic, or the exudation of 
liquid be slow, and its quantity be small, the respiratory murmur may be 
vesicular, though faint and distant, during the whole course of the 
39 



610 PLEURITIS. 

attack. Sometimes when the murmur is vesicular in the greater part of 
the lung, broncho-vesicular or bronchial respiration is heard over a limited 
area, where the effusion happens to be sufficient to produce requisite 
compression of the lung. 

The voice of the patient, when auscultated over the affected side, has 
a character which corresponds with and varies according to the respiratory 
murmur. Yocal resonance is feeble or absent if the respiratory murmur 
be vesicular. If it be bronchial, the auscultated voice is more distinct, 
having the character known as bronchophony, or when there is a mod- 
erate quantity of liquid over the lung, so that this organ vibrates, it may 
have that modification of bronchophony known as egophony. Occasion- 
ally we can hear the voice as a confused and distant sound, when the 
quantity of liquid is so great that respiration is inaudible. The signs de- 
rived from the auscultated voice are not, as is well known, pathognomonic 
of liquid effusion. Bronchophony is more common and distinct in pneu- 
monic or tubercular solidification of lung than in pleuritis, and even 
egophony may be produced without the presence of a liquid, by " pleural 
membranes realizing certain physical conditions" (Jaccoud). But since the 
auscultated voice is weaker in children than in adults, we often do not 
hear it in infants and ill-conditioned children, even when the anatomical 
conditions, as regards the lungs and pleural cavity, are favorable for its 
transmission. 

In children as in adults, bronchial rales are common in pleuritis, dry or 
moist ; coarse when produced in the larger tubes, or fine when occurring 
in the finer tubes. 

Diagnosis. — Ordinarily, a careful observance of the history, symptoms, 
and physical signs enable the physician to make a positive diagnosis. 
Obscure or doubtful cases occur chiefly in infancy. Circumscribed pleu- 
ritis, or pleuritis attended with little or no liquid exudation, is obviously 
most apt to be overlooked, and its symptoms mistaken for those of an- 
other disease. 

Pleuritis, before the stage of exudation, may be mistaken for pneu- 
monitis, since the prominent symptoms in the commencement of the two 
diseases are similar. But in pleuritis there are commonly greater acceler- 
ation of pulse and respiration, greater suffering, as evinced by the fea- 
tures, greater tenderness on percussing or pressing the chest- wall, and a 
more decided expiratory moan, while the patient probably endeavors to 
repress respiration on the affected side, so that inflation of the lung is 
partial and shallow. It will aid in the diagnosis to recollect that, in chil- 
dren under the age of five years, acute pneumonitis is, in most instances, 
catarrhal, and not croupous, and is preceded and accompanied by severe bron- 
chitis, being due to downward extension of the inflammation from the bron- 
chial tubes. It therefore does not begin with the abruptness of pleuritis. 

Pleuritis with effusion may be mistaken for pneumonitis in the stage of 
solidification, for hydrothorax, or, on the left side, for pericardial effu- 



DIAGNOSIS. 611 

sion, or vice versa. But the percussion sound over a pleuritic exudation 
is either tympanitic or flat, while over a lung solidified by inflammation it 
has some resonance, though dull. There is also a sensation of greater 
resistance and solidity in percussing over a pleuritic exudation than over 
an inflamed lung. Moreover, the respiratory murmur, whether vesicular, 
broncho-vesicular, or bronchial, is more distant and less distinct to the 
ear of the auscultator when applied over a liquid than over a solidified lung. 

A pleuritic exudation, unless slight, also changes the apex-beat of 
the heart, pressing it toward the median line in left pleuritis, and away 
from the median line in right pleuritis, as has been stated above — a 
change not observed in pneumonitis. Bulging of the intercostal spaces, 
expansion of the chest-walls, change in the height of the fluid by change 
in the position of the child, important signs in the diagnosis of adult 
pleuritis, are, as we have seen, commonly absent in young children, even 
when there is abundant liquid effusion, but they are sometimes observed 
in children of a more advanced age. Bronchophony and vocal fremitus, 
signs of pneumonic solidification, are absent, or so feeble in the pneu- 
monitis of young children that their absence cannot be regarded as indi- 
cative of the presence of pleuritic effusion, except in children over the age 
of four or five years. Moreover, these signs, when present, do not neces- 
sarily indicate pneumonitis, for if, in pleuritic effusion, the ear or hand 
be placed over a part of the chest where adhesions have united the lung to 
the ribs, and the child be of such an age that the vocal cords have suffi- 
cient vibration, both bronchophony and the fremitus may be perceived. 
The absence or presence, therefore, of vocal fremitus and bronchophony 
affords only limited assistance in the differential diagnosis of pleuritis and 
pneumonitis in young children. In those of an advanced age whose 
vocal cords have greater vibration it aids in the discrimination of doubtful 
cases, especially if the examination be made in the infra-scapular region, 
which corresponds with the location of the liquid, if any be present. 

A pleuritic effusion is distinguished from hydrothorax by the fact that 
the latter is usually bilateral and of slow increase, without symptoms 
referable to the chest, except when there is considerable effusion, which 
causes more or less dyspnoea. Pleuritis, unlike hydrothorax, causes fever 
and other constitutional symptoms, and also a cough, pain in the chest, 
and early embarrassment of respiration. Moreover, hydrothorax seldom 
occurs, except from cardiac or renal disease, or scarlet fever. 

A greatly distended pericardial sac simulates, in some degree, a pleu- 
ritic effusion on the left side, but the absence of symptoms which pertain 
to pleuritis, as the cough, stitch-like pain in the chest, the localization or 
greater distinctness of the dull sound on percussion, in the cardiac region, 
absence or feebleness of the apex-beat, and indistinctness or distance of the 
heart-sounds, will preserve the observant physician from error of diagnosis. 

Prognosis. — In mild cases attended with little exudation, the inflamma- 
tion soon begins to abate, and, by the close of the second week, the 



612 PLEUKITIS. 

symptoms have nearly disappeared. In plastic, and sero-fibrinous pleu- 
risies, recovery may be confidently expected, unless there be some grave 
complication, or perchance syncope should occur from large and rapid 
effusion. A large effusion, whatever its character, especially if located 
on the left side, often causes such a twist in the great vessels within the 
thorax as to seriously retard the circulation of blood and endanger life. 
In effusions of the left side, the heart is often carried so far toward the 
right that the ascending vena cava, where it emerges from the central 
tendon of the diaphragm, is bent at an angle so as seriously to obstruct 
the return of blood from the lower half of the body, and consequently a 
reduced quantity of blood reaches the right cavities and the pulmonary 
artery. The result is a diminished flow of blood in the systemic circula- 
tion, with anaemia of important organs, as the brain. The great arteries 
connected with the heart are also more or less bent in cases attended by 
displacement of this organ. In effusions on the right side, the right auri- 
cle and ventricle sometimes do not expand to the normal extent during 
the diastole, on account of the pressure of the liquid, and the result is 
similar to that in effusions on the left side, as regards obstructed circula- 
tion and anaemia of important organs. Therefore, patients with large 
pleuritic effusions, whether left or right, are liable to sudden fainting and 
even to fatal syncope. Fortunately, with our present improved methods 
of thoracentesis, children need not perish in this way if the operation be 
resorted to at the proper moment. There is another danger. When, in 
consequence of the exudation, the lung is so compressed that its function 
is nearly or quite lost, the sound lung obviously receives an augmented 
supply of blood. It is, therefore, very liable to sudden congestions and 
transudation of serum (oedema). If this occur, the dyspnoea is augmented 
and the condition is one of the utmost peril. Death is apt to result. 

The prognosis obviously varies according to the cause of the inflamma- 
tion and the quantity and nature of the exudation. Idiopathic pleurisies 
do better as a rule than those which occur as a complication or sequel of 
some other disease. Absorption is more rapid in the beginning of con- 
valescence, when the fluid is thin, than at a later period, when it has 
greater consistence. Fibrin, whether flocculent or laminated, is necessa- 
rily slowly absorbed, first undergoing fatty degeneration and liquefaction. 
Empyaema, if not relieved by operative measures, continues many months, 
and even after pus is let out convalescence is slow. In the very consider- 
able number of empyaemic cases which have from time to time been 
brought to the class of children's diseases in the Bureau for the Relief of 
the Out-Door Poor, the histories commonly showed that the disease had 
continued from three to six months, with progressive loss of flesh and 
strength. Nevertheless, after proper evacuation of the pus and establish- 
ment of a fistulous opening, the majority have gradually recovered, death 
in the unfavorable cases being commonly due to extreme prostration with 
perhaps fatal organic changes, as amyloid degeneration and tuberculosis. 



PROGNOSIS. 613 

Secondary pleuritis occurring in a reduced state of the system, as after 
scarlet fever, and pleuritis complicated by a grave disease, as pericarditis 
or pneumonia, are always dangerous to life. 

It is the common belief that pleuritic effusions involve greater danger on 
the left than on the right side, from the fact that the former produces 
more immediate and direct pressure on the heart and cause a greater 
twist in the vessels, but Leichtenstern (Deutsches Archiv fur Klin. Med., 
Band iv.) states that, in 52 cases of sudden death from pleuritic effu- 
sions, 31 were right and 20 left pleurisies. The walls of the right cavi- 
ties of the heart, upon which the liquid in the right pleural cavity 
directly presses, are thinner and therefore more yielding than the walls of 
the left cavities. The records of the cases collected by Leichtenstern show 
that sudden death sometimes results from extensive and far-reaching 
thrombi in the right cavities of the heart and in the superior vena cava, 
or to emboli detached from the thrombi and intercepted in the pulmonary 
artery. In grave cases attended by large effusion, sudden death some- 
times occurs after some exertion on the part of the patient, as after vomit- 
ing, severe coughing, or hurried rising to the erect position, or lifting a 
heavy weight. It is believed that, under such circumstances, there is a 
retarded flow of blood through the lungs and into the left cavities of the heart 
and the aorta, so that sudden and fatal anaemia of the brain is produced. 

As already stated, death may occur in protracted cases from amyloid 
degeneration of important organs, as the kidneys and liver. This can 
sometimes be detected by enlargement of liver and spleen, and the occur- 
rence of albuminuria. 

It is evident that the prognosis varies greatly according to the degree 
of dyscrasia. In profound blood-poisoning, whether scarlatinous, urae- 
mic, or septicemic, pleuritis is always grave. Septic pleuritis, which 
occurs for the most part in new-born infants, during epidemics of 
puerperal fever, is especially so. When it has continued a few hours, the 
pinched features and rapid sinking show that we have to deal with 
something more than an ordinary attack.* 

* The following case which occurred in my practice during the recent epi- 
demic of puerperal fever (1881) may be adduced as an example : Mrs. D., a 
primipara, was delivered by the forceps after a tedious labor, at 9 p.m., April 
6th. On the following morning, her temperature, without the occurrence of a 
chill, had risen to 105£°, and her pulse varied between 125 and 134. She was in 
a critical state for several days, with a temperature varying between 103° and 
105£°, and without any local symptoms either of metritis or cellulitis, but finally 
recovered. The baby, healthy and vigorous at birth, had been allowed to obtain 
what nutriment it could from the breast, but the nurse remarked that she " never 
saw a child sleep so much," and I gave very little attention to it, as my time was 
devoted wholly to the mother. On the 10th, when four days old, its sleepiness 
ceased, and it became constantly fretful, as from colic, and it refused to draw 
upon the nipple. Early in the morning of the 11th I was summoned to it, and 
was astonished at its altered appearance, its shrunken features, and its evidently 



614 PLEURITIS. 

Pleuritis is also very severe, and ordinarily fatal, when it is caused "by 
the entrance of some pathological product into the pleural cavity, as pus 
or decaying lung substance. 

Treatment. — It will be convenient, in considering the treatment, to de- 
scribe that which is appropriate for each of the three stages into which 
systematic writers have divided pleuritis. First, the stage preceding effu- 
sion, secondly, that of effusion, and thirdly, that of absorption and con- 
valescence. In the beginning of the inflammation, appropriate measures 
should be promptly employed for the purpose of reducing the inflamma- 
tion, and preventing or diminishing, so far as possible, the exudation 
which soon follows. The abstraction of blood is now properly discarded 
in the treatment of most inflammations of infancy and childhood, but in 
certain cases of pleuritis occurring in robust children over the age of four 
or five, or even three years, the early and judicious employment of one or 
two leeches diminishes the pain and apparently also for a time the febrile 
movement and the inflammation. But it may be stated as a rule that the 
loss of blood is not only not required, but is injurious in all secondary 

dying state. Percussion upon the right side gave a flat resonance from the 
clavicle to the diaphragm, and there was some meteorism in the abdomen. The 
thermometer introduced into the rectum showed no elevation of temper- 
ature, and no unusual heat of surface or cough had been noticed by the nurse. 
By active stimulation the infant lived till the middle of the afternoon. The 
autopsy revealed a sero-fibrinous exudation filling the right pleural cavity, pro- 
ducing complete carnification of the lung, so that it resembled that of the fcetal 
state, and soft patches or flakes of fibrin upon the lungs. By an oversight, the 
peritoneum was not examined. Cases like this, of pleuritis in the new-born 
having a septic cause, I believe to be rare, and met only or chiefly during epi- 
demics of childbed-fever. Some years ago I saw a new-born infant in one of the 
institutions, whose mother had puerperal fever, die in a similar manner, and the 
autopsy showed that the cause was peritonitis. The following extracts from 
Trousseau's clinical lecture on erysipelas of new-born infants will aid in under- 
standing such cases. Speaking of Dr. P. Lorain, he says : " During the epidemic 
at the maternity, where this able and laborious observer was a resident pupil, 
he collected the information of which the following is a summary : Of 106 still- 
born infants, 10 were found to have died from peritonitis, and 3 of the mothers 
of these 10 infants were carried off by puerperal fever after delivery. Of 193 
infants born alive, 50 died of the very same affections which proved fatal to the 
lying-in women. The most frequent causes of death were peritonitis, numerous 
abscesses, purulent infection, phlegmonous swellings, erysipelas, gangrene of the 
limbs, putrid infection, or some other remarkable septic condition." . . " Mother 
and child then are subject to the same morbific influence." Farther on Trous- 
seau says of the infant affected by this puerperal poison : " He will cry inces- 
santly from pain. A state of restlessness will be succeeded by collapse, which 
will close the scene on the fifth, sixth, or seventh day. On examining the body 
after death, pus will be found in the cellular tissue, sometimes suppurative pleurisy , 
more frequently phlebitis of the umbilical vein, or of the vena porta, or peritoni- 
tis." An interesting incidental fact shown by these statistics is that the cause of 
this puerperal disease of the new-born is sometimes operative in the fcetal state. 



TREATMENT. 615 

pleurisies, and in the primary form after exudation has occurred. It is 
injurious in all forms of pleuritis in pallid and cachectic children, and, 
therefore, in a large proportion of the cases occurring in the tenement- 
houses and institutions of the cities. The flow of blood from the bites 
should ordinarily be arrested after two or three hours, but if slight, it 
may continue longer in vigorous children of eight or ten years. 

At the first visit of the physician, an emollient and slightly irritating 
poultice should be ordered, enveloping the entire chest, to be constantly 
worn, except as it is temporarily removed during the application of the 
leech, and the subsequent flow of bloodo The poultice should be so mildly 
irritating that it causes constant redness of the skin without pain, and it 
should not be removed except when a fresh poultice is prepared to replace 
it. Thus employed it produces constant dilatation of the capillaries of 
the skin, and, by the fluxion caused, diminishes, in my opinion, the 
engorgement of the capillaries of the costal pleura. A poultice of the 
common white mustard, with flaxseed in powder, one part to sixteen, be- 
tween two pieces of muslin, and so wet that it moistens the hand in hold- 
ing it, produces this effect. Applied morning and evening, it can be con- 
stantly worn without complaint of pain due to it. For infants under the 
age of eight months, I prefer the use of the plain flaxseed, with cam- 
phorated oil smeared upon its under surface. The oil may be applied 
several times daily, while the morning and evening application of the 
poultice is sufficient. Spongiopilin or compresses of flannel wrung out of 
hot water and covered with oil-silk meet the indication, and possess the 
advantage of being lighter and cleaner, and more readily applied than the 
poultice. Redness may be produced, by applying under the spongiopilin 
a single thickness of muslin soaked with camphorated oil, or for children 
of a more advanced age, with camphorated oil and one fourth or one 
third part of turpentine. 

Vesication, formerly much employed, has properly nearly fallen into 
disuse in the treatment of the pleuritis of children. While it is apt to 
increase the suffering, it has apparently no tendency to diminish the inflam- 
mation, in whichever stage employed, and there is no certainty that it 
stimulates the absorbents and expedites the removal of the liquid, accord- 
ing to the old theory. A case is reported, in the practice of one of the 
New York physicians, in which a blister had been applied when the in- 
flammation was still active, and at the autopsy, the portion of the costal 
pleura which lay directly underneath the surface that had been vesicated 
was covered by a thicker fibrinous exudation than that upon the contigu- 
ous surface. The increased afflux of blood caused by the blister had, to 
appearance, extended to the costal pleura, and increased the pleuritis. 
The application of cold bandages around the chest, which is recommended 
by some, seems to aggravate the cough in certain patients, and does not 
ordinarily give the relief of moist and warm applications. 



616 PLEURITIS. 

Internal Remedies. — The indications are to employ such medicines as- 
diminish the frequent action of the heart, and thus retard, in a measure, 
the flow of blood to the pleura, and such as diminish the pain and fre- 
quency of the cough, which, by increasing the friction of the pleural sur- 
faces, tends to increase the inflammation. For robust children over the 
age of three years in the first stage of primary pleuritis, the tincture of 
aconite may be prescribed, half a drop for a patient of three years, and 
one drop for one of six years, every third hour for two or three days, or 
until the required effect be produced upon the pulse, when it should be 
discontinued. It is, as a rule, too depressing for other patients. Digitalis 
is a better and safer remedy for children under the age of three years for 
all secondary pleurisies, and for all cachectic cases. Benefit results from 
continuing the use of digitalis in the stage of exudation when aconite 
would be inadmissible. A child of two years can take one drop of the 
officinal tincture, and one of five years two drops every three hours. 

The use of quinia is suggested, since it is an antipyretic and tonic, but 
in my practice it has been much less useful in pleuritis than in pneu- 
monitis. This agent, in whatever form given, does not appear to exert 
any notable controlling effect either on the fever or gravity of pleuritis. 
Nevertheless, I have often employed it, especially in secondary pleurisies, 
with or without digitalis, and it probably does some good as a tonic. 
The salts of quinia, as ordinarily given in solution to young children, are 
very apt to be vomited. When vomited, a soluble salt, as the bisulphate, 
may be given as a suppository, or Squibb 's oleate of quinia may be em- 
ployed by inunction. I should, however, add that, though I have used 
inunctions of the oleate in pleuritis during the last year, ten grains of the 
alkaloid, at a time, I have not seen any marked beneficial effect. To 
meet the second indication in the treatment of the first stage, namely, to 
relieve the pain and restlessness, and to diminish the cough, so that there 
is less friction of the pleural surfaces, our chief reliance must be on 
hyoscyamus or one of the opiate preparations. The following formulae 
will be found useful : 

R. Tinct. opii deodorat, gtt. xx ; 

Tinct. digitalis, gtt. xvi ; 

Syr. pruni Virginian, 1 j : 

Aquae, §iss. Misce. 
Dose, one teaspoonful (one drachm) every three hours for an infant of 
eighteen months. The tincture of hyoscyamus may be employed in place of 
the opiate in double the dose. 

For a child of three years : 

. Tinct. ipecac, comp. \ 

(Squibb's liquid Dover's powder), V aa gtt. xxxij. 
Tinct. digitalis, ; 

Syr. pruni Virginian, fij. Misce. 
Dose, one teaspoonful every two or three hours. 



TEEATMENT. 617 

For a robust child of eight years with primary pleuritis : 

9. Morph. sulphat., gr. i. 
Tine. rad. aconit., gtt. xx. 
Syr. pruni Virginian, 1 iiss. Misce. 
Dose, one teaspoonf ul every three hours. 

The diet in the first stage should consist of milk and farinaceous food, 
given liberally. The meat-teas or the expressed juice of meat may be 
added, and in secondary pleurisies, as after scarlet fever, it is often 
proper to give a moderate amount of alcoholic stimulants from the first. 

Second Stage. — Measures employed in the first stage have been de- 
signed to diminish the inflammation and relieve suffering. The duty of 
the physician, in the treatment of the second stage, is chiefly to aid in 
the removal of the inflammatory product, and prevent, so far as possi- 
ble, its further formation. If this be sero-fibrinous, and its quantity be 
small, so as to fill only the lower portion of the cavity, little aid may be 
needed from therapeutics ; but a larger effusion, compressing the lung 
and displacing the heart, requires medicinal and often surgical measures. 
The recommendation of Niemeyer, that the patient's food contain little 
liquid, and that his drinks be restricted, as a means of increasing the ab- 
sorption from the pleural surface, is not applicable to young children, 
whose diet must of necessity be largely liquid, and that of infants chiefly 
milk. 

Attempts to stimulate the absorbents by external treatment of the chest 
are of doubtful efficacy, whether by the application of the so-called small 
flying-blisters, the iodine ointment or tincture, or a stimulating liniment. 
The common practice of treating glandular swellings by iodine applica- 
tions suggests their use for pleuritic effusions, and of the agents employed 
locally to hasten absorption they are probably the best, but they should 
not be used so often or in such quantity as to cause pain or restlessness 
from their irritating effect. 

It is an established principle in therapeutics that the removal of a serous 
liquid in either of the larger cavities of the body is hastened by such rem- 
edies as produce an abundant liquid secretion or transudation from any of 
the organs or surfaces. Hence in the treatment of pleuritic effusions, 
those medicines which act on the skin causing diaphoresis, upon the in- 
testines causing watery stools, and upon the kidneys causing diuresis, are 
at once suggested as most likely to be efficacious. But sudorifics, though 
useful for dropsies having a renal origin, have not been much used of late 
years for the removal of exudations in the pleural cavity, experience hav- 
ing shown that they are inadequate for this purpose. Recently, however, 
the discovery of a very active agent of this class, jaborandi, has revived, 
in a measure, the sudorific treatment of the second stage, so that in the 
National Dispensatory of Stille and Maisch this diaphoretic is one of the 



618 PLEURITIS. 

recommended remedies. Having witnessed the effect of jaborandi in 
various diseases, I am persuaded that the risk attending its use for pleu- 
ritic effusions more than counterbalances any good result which might 
accrue. The heart, crippled in its action by the pressure of the liquid, 
badly tolerates agents of a depressing nature, and there is little doubt that 
jaborandi, or its active principle pilocarpin, exerts a weakening effect on 
this organ. 

Again, the fact that sero-fibrinous exudations have been known to 
diminish rapidly during attacks of diarrhoea suggests the use of purga- 
tives ; but, although an open state of the bowels, as two or three daily 
stools, aids absorption, free purgation is badly borne by young or feeble 
children, as it reduces the strength, and, therefore, like the use of jabo- 
randi, is not to be recommended as a therapeutic measure. Moreover, 
there is not the need of employing severe or exhausting medicines for the 
removal of the liquid, which may have existed in former times, since we 
are able to accomplish this quickly, easily, and safely by the excellent 
aspirating instruments now in common use. 

Diuretics, on the other hand, are apparently more useful, while they 
are less exhausting, than sudorifics or cathartics. Digitalis, combined 
with the citrate or acetate of potassium, has stood the test of experience, 
and is now more widely used than any other agent of this class. Being 
both a diuretic and heart tonic, it possesses properties which render it 
especially serviceable in the treatment of pleuritic effusions. The follow- 
ing is a useful prescription for a child of five years : 

R • Potassii acetatis, 3 i j ; 

Infus. digitalis, §iij Misce. 
Give one teaspoonful every three hours. 

It is a matter of observation that absorption occurs more rapidly, and a 
sero-fibrinous is less likely to become a purulent effusion, if the bodily con- 
dition be good. Hence tonics, especially the bitter vegetables, are some- 
times useful, and a diuretic in combination with a tonic, as the acetate 
of potassium in decoction of cinchona, may often be prescribed with 
advantage. 

Still, however judicious the treatment, hygienic and medicinal, many 
cases require surgical interference, and the number of such is certainly 
larger in the city than in the country, and in the tenement-houses than in 
the better walks of life, since the cachexia so common in city children in- 
creases the liability to purulent exudations. 

Thoracentesis. — The indications for the operation are the following : 

1st. Dyspnoea due to the presence of the liquid, whether it be sero- 
fibrinous, purulent, or haemorrhagic. Usually when dyspnoea occurs, the 
pleural cavity is full, but if there be parenchymatous disease of either 
lung, a moderate quantity of liquid may cause such embarrassment of 
respiration that thoracentesis is indicated. 



TREATMENT. 619 

2d. A flat percussion sound over the entire affected side, with displace- 
ment of the heart, even if there be no present dyspnoea, is also an indication 
for the operation, for dyspnoea might occur suddenly with other alarm- 
ing symptoms between the visits of the physician. Moreover, experience 
has shown that absorption from a distended pleural cavity is very tardy, 
in consequence of compression of the absorbents, whereas, if a portion of 
the liquid be removed, absorption of the remainder is more rapid. The 
patient with full pleural cavity and lung totally compressed lies on the 
affected side, and is apt to feel uncomfortable in any other position, and 
the withdrawal of a portion of the liquid, as, for example, one half, the 
operation being discontinued when the patient begins to cough or evince 
distress, produces no ill-effect, and increases the comfort. 

3d. A moderate effusion, without material decrease in quantity after 
some weeks of observation, also indicates the need of surgical interfer- 
ence, since long compression of a lung involves risks. There is danger 
that catarrhal ending in cheesy pneumonia and tubercles may occur in a 
lung whose function is long suspended ; besides, the longer compression 
has existed, the more tardy, difficult, and incomplete will be the inflation 
when the liquid is removed, on account of the altered state of the alveoli, 
and the presence of fibrinous bands over the lung. Thus, in a case 
recently under observation, only partial inflation of the lung occurred, 
after letting out the liquid, so that the ribs and shoulder on the affected 
side are permanently depressed, and unequivocal symptoms of tuberculosis 
are now present. 

4th. If the inflammation extend to the pericardium, so as to cripple the 
heart's action, or if there be any serious pre-existing heart-disease, the 
liquid, even in moderate quantity, may, by pressure, so embarrass and 
retard the heart's action that its cavities are not properly filled, so that 
passive congestion of certain organs, and dangerous anaemia of others, 
especially of the brain, may result. Under such circumstances, an early 
performance of thoracentesis is indicated. 

5th. Empyema. — The presence of pus in the pleural cavity affords in 
itself, in a large proportion of cases, sufficient indication of the need of 
thoracentesis. In recent cases, with only moderate constitutional disturb- 
ance and embarrassment of respiration, if we ascertain by the hypodermic 
syringe that the liquid is only slightly clouded by leucocytes, surgical in- 
terference may be postponed, while the acute inflammation is treated. 
Thus, in case of an infant of two months, thin pus was withdrawn on the 
fourth day of acute pleuritis, and, although thoracentesis was early per- 
formed, it appeared probable, from the subsequent course of the case, that 
it would have been as well had the operation been deferred. If spontane- 
ous evacuations of pus have occurred through one of the intercostal 
spaces, producing a fistula, from which there is a daily oozing, or if it be 
probable, from the symptoms and signs, that pus is escaping from the 



620 PLEURITIS. 

pleural cavity into a bronchial tube, and is being gradually expectorated 
—a mode of cure which, as I have elsewhere stated, is not infrequent in 
children — thoracentesis may be deferred. In the case of an infant, aged 
six months, recently under treatment for empyema of the left side, we 
removed four ounces of pus, and washed out the pleural cavity. The 
opening having closed, and the physical signs indicating the re-accumula- 
tion of a considerable quantity of liquid, we were preparing for a second 
operation, when the parents and nurse called our attention to the fact that 
there were occasional severe attacks of coughing, during which the breath 
presented a very decidedly purulent odor. Although there was no exter- 
nal expectoration, as the sputum was swallowed, thoracentesis was post- 
poned, and the result justified the decision, for the patient gradually con- 
valesced. Except under circumstances like the above, empyema, when 
clearly diagnosticated, by the employment of the hypodermic syringe, 
should be promptly treated by evacuation of the pus. 

Instrument to be Used, and Mode of Operating. — Ingenious instruments 
for tapping the chest have been invented by Dr. Chadbourne, of the New 
York Foundling Asylum, Dr. A. M. Phelps, of Chateaugay, Franklin 
Co., N. Y., and others, which, by india-rubber packing, totally exclude 
air, while the operation is performed with facility and little pain. That 
devised by Dr. Chadbourne has a canula with two arms, one for attach- 
ment, by means of tubing, to the exhausting receiver, and the other is de- 
signed to facilitate irrigation of the pleural cavity. 

Phelps' apparatus has a third tube, entering the bottle through the 
stopple, and a glass tube passes from the stopple to nearly the bottom of 
the bottle. With this apparatus, by reversing the movement of the 
syringe, the liquid can be withdrawn from the chest, the bottle emptied 
of it, the water used for irrigation be conveyed into the bottle, from the 
bottle to the chest, and back into the bottle, without changing the posi- 
tion of the bottle or removing the stopple. I would suggest the use of 
the trocar and canula instead of the sliding aspirator point which plays 
outside the canula, as an improvement in this instrument. 

The instrument which I have been in the habit of employing is of sim- 
pler construction. The canula has about the size of the smallest needle 
of Dieulafoy's aspirator ; the proper size, in my opinion, for thoracentesis, 
for both sero-fibrinous and purulent exudations. I greatly prefer the use 
of the exhausting-bottle rather than the exhausting- pump without the 
bottle, as it is more convenient and produces greater suction, from its 
greater size. The canula is provided with an arm, which connects it by 
tubing with the exhausting-bottle. Beyond this arm, the body of the 
canula, sufficiently expanded to contain india-rubber packing, extends 
about one and one half inches, and is provided with a stop-cock. Through 
this packing the trocar is introduced, and, after the puncture, it is with- 
drawn to the stop-cock, which is then turned to prevent the admission of 



TREATMENT. 621 

air. Then the obturator is introduced in place of the trocar, so as to re- 
move any obstruction which may enter the canula. 

The tubing which extends from the arm of the canula to the bottle 
should be firm, with a somewhat larger bore than that of the canula, and 
its point of attachment to the bottle should also be provided with a stop- 
cock. A short glass tube introduced into this tubing near the canula is 
convenient for noticing the character of the fluid, which, if it be thick 
pus, may flow with difficulty, and not reach the bottle. A bottle of 
sufficient capacity to hold two quarts obviously produces more suction 
power than one of less size, and is, therefore, preferable for certain cases, 
and its sides should be marked to indicate ounces and drachms. The 
tube which connects the canula with the bottle enters through the stop- 
ple, and proceeding from the stopple is another tube similar to the first, 
to which the syringe is attached. The syringe has two points for attach- 
ment to the tube, and a double action in its interior, so that attached by 
one point, it exhausts the air from the bottle, and attached by the other 
point, it condenses air in the bottle. The stop-cock between the canula 
and the bottle should always be closed when the syringe is used, whether 
for exhaustion or condensing. It is very important that this should be 
constantly borne in mind when working the syringe, or air may be 
thrown into the pleural cavity and much harm done. 

Mode of Operating for Sero-fbrinous Exudations. — In the following 
remarks I shall state what I consider the best method of performing 
thoracentesis, having formed my opinion from the cases which I have 
witnessed and been able to follow, in the institutions and in family prac- 
tice. A mode of treatment which may be safe and proper for the adult 
is not always the best for the child, and, as there are different opinions 
and different modes of procedure, and as many who are familiar with 
adult cases recommend similar treatment for the child to that which they 
have employed with success for the older and more robust cases, I shall 
advise the abandonment of certain measures which are in common use, 
and the substitution of others. The hypodermic syringe should be first 
introduced at the point where it is proposed to perform the operation, 
the needle being inserted about one inch, for I hold it unjustifiable to tap 
the chest without first ascertaining that there are no adhesions at the site 
selected for puncture, and at the same time ascertaining the character of 
the liquid. Incision of the skin with the knife and spraying the surface 
with ether are not required as preliminary treatment, since the puncture 
is quickly and easily performed with a small trocar, and with very little 
pain. The rule is established by many observations that the operation 
should be performed in or near the vertical line passing through the angle 
of the scapula, and between the eighth or ninth ribs, or one of the adja- 
cent intercostal spaces. I have elsewhere stated that a point a little exter- 
nal to this line is preferable, as the lung is less likely to be injured. The 



622 PLEURITIS. 

instrument should obviously be inserted no farther than will be sufficient 
to reach the liquid, and, as from measurements which I have made, the 
thickness of the thoracic wall in rather fleshy children is about half an 
inch, penetration to the depth of one inch will ordinarily be sufficient to 
pass the fibrinous layer. We are apt to puncture more deeply than is 
necessary without some safeguard, and incur the risk of wounding the 
lung. India-rubber tubing may cover the instrument to within one inch 
of the end, or a cord may be tied snugly around the instrument at one 
inch from the tip. The sensation communicated to the fingers will, how- 
ever, be the best guide to the careful operator as regards the exact depth 
to which the instrument should be carried. The trocar should now be 
withdrawn, the obturator introduced in its place, the air exhausted from 
the bottle, and then the stop-cock turned, to allow the liquid to escape. 

It should flow slowly, as it probably will, through so small a canula, 
but the flow can be regulated by the stop-cock. The quantity to be re- 
moved depends upon the age *nd condition of the child, the size of the 
cavity, and the quantity of the liquid, but if the patient begin to cough 
or feel uncomfortable after the removal of one half, or even one third of 
the liquid, the canula should be withdrawn. The sensation of insufficient 
breath is no longer experienced, and the remaining liquid is progressively 
absorbed. This operation is one of the easiest in surgery, while, with 
the precautions mentioned above, no ill effect need be apprehended. One 
operation is, in most instances, all that is required, though, if need be, 
it can be repeated after some days, and it is very seldom that the lung 
does not fully expand to fill the chest if the operation be performed at the 
proper time. 

Mode of Operating for Empyema. — It will aid in understanding this 
part of our subject to remember that all pleuritic exudations contain pus- 
cells, and that the only anatomical difference between sero-fibrinous exu- 
dations and empyema is in the proportion of these cells. There is, there- 
fore, no fixed and definite boundary line between the two kinds of exuda- 
tion. The term of empyema is, as all know, applied by common usage 
to the liquid when it contains so many leucocytes or pus-cells that a turbid 
appearance is imparted to it. Absorption is slow and difficult, or impos- 
sible, if the liquid contain a large amount of solid ingredients, namely, 
fibrin and pus-cells, while liquid containing only a small proportion of 
these constituents more readily enters the absorbents. In other words, 
thin pus may be absorbed and removed from the system by natural 
methods, or by the same instrument and operation which we have recom- 
mended for sero-fibrinous exudations, while a thick liquid adherent to the 
pleura, or sinking heavily in dependent portions of the cavity, disappears 
very slowly, losing by absorption only a little of the liquor puris, while 
the bulk of it cannot be absorbed, so that the only relief is by evacuation 
through an opening. Often in practice, after the acute symptoms of an 




TREATMENT. 623 

empyema have in a measure abated, the physical signs indicate some 
diminution of the liquid in successive weeks, but further removal soon 
comes to a standstill, and the resources of surgery must be tried. 

In my opinion, the same small trocar and canula should be used for 
tapping the chest of an empyemic child which we have recommended for 
sero-fibrinous exudation, and with the same precautions. If the liquid 
be thin and but slightly turbid, if it be but little removed from sero-fibrin 
in its character, it will flow through the canula, even if it be necessary to 
use the obturator often to remove obstructions. Having withdrawn all 
the liquid which will flow through the opening, unless severe coughing or 
some unpleasant symptom occur, which is an indication to discontinue the 
withdrawal, the instrument is removed, and the aperture may be closed 
with adhesive plaster. One operation may be sufficient to effect a cure, 
though convalescence in empyema is tardy under the most favorable cir- 
cumstances. If we observe from week to week some return of appetite, 
more cheerfulness and sleep, easier breathing, and less frequent cough, 
the case can be left to hygienic management and restorative medicines. 
But if the improvement be only temporary, and after some days exam- 
ination shows that the liquid has re-accumulated to nearly or quite its 
former quantity, and symptoms occur which indicate the need of surgical 
interference, the operation should be repeated. The use of so small an 
instrument produces no shock or prostration, and very little more pain 
than occurs from the hypodermic injection of a medicine. 

And now I come to a subject in regard to which my observations have 
led me to differ from some whose opinions I respect. If the liquid be 
so thick, so heavily loaded with leucocytes that it do not pass through the 
canula, what shall be done ? Shall a larger instrument be used, as one 
corresponding in size with the medium or even large needle of Dieula- 
foy's aspirator, or shall a free incision be made with a knife ? The lat- 
ter, I am convinced, is the proper alternative. The canula may serve as 
a director, and an incision should be made with the sharp-pointed bis- 
toury along the upper border of the rib, sufficiently large to admit the 
blunt-pointed bistoury, and with this the incision should be extended to 
the distance of one third to one half inch, which will allow the pus to 
flow out freely. The opening should then be covered by oakum confined 
by long strips of adhesive plaster. Pus may or may not continue to flow 
into the oakum. If it do not, the opening will close, if left to itself, 
within two or three days. No tent or drainage-tube is employed, for 
reasons to be mentioned hereafter. The physician should return after 
twelve or twenty-four hours, not later, and should introduce through the 
opening the ordinary gum-elastic male catheter, warmed so as to be flexi- 
ble, and strongly bent at its middle. The point should be directed to 
the bottom of the cavity. Perhaps the soft rubber catheter might be 
preferable, but I have never used it, being satisfied with the other. The 



624 PLEURITIS. 

catheter should be attached by tubing to the exhausting-syringe or bottle, 
and any pus in the depending portions of the cavity will be readily re- 
moved. I have generally, at this visit, removed from the bottom of the 
cavity two or three ounces, sometimes very thick, and such as would not 
readily flow from the opening. Every day or twice daily the operation 
should be repeated, which will, I think, more effectually remove the pus 
than washing out the cavity, and the opening cannot close. This opera- 
tion detains the physician only a few moments. The catheter should be 
a No. X., and it is the best possible probe. By the close of the first 
week the opening becomes fistulous. 

After each removal of the pus, long strips of adhesive plaster firmly ap- 
plied over the ribs, from the sternal region downward and backward, 
facilitate approximation of the pleural surfaces and obliteration of the 
cavity. Daring convalescence, the patient, if old enough, should be 
directed to make full inspirations, which serve to expand the lungs. 

That thoracentesis, so simple and important an operation, should have 
been known and practised by the ancients, even, it is said, by Hippo- 
crates, and have fallen into disuse, till it was revived, in our own times, 
by Bowditch and Trousseau, seems remarkable. This was probably in 
part due to the bad instruments employed, and in part to the fact that in 
olden times the operation was performed in the anterior walls of the 
chest, where adhesions are very apt to be present. But there are certain 
accidents and unfavorable results of the operation which may be profita- 
bly considered, since, in my opinion, they can nearly always be avoided. 

1st. The Admission of Air into the Pleural Cavity. — This is unneces- 
sary, and can be avoided ; but those who have often witnessed the op- 
eration, as ordinarily performed, have remarked the fact that the ad- 
mission of more or less air is common. 

The entrance of a certain amount of air into a serous cavity, when the 
serous membrane is in its normal state, does not appear to be productive 
of harm with ordinary precautions, as regards temperature, etc., as in 
ovariotomy, in which air is admitted into the largest serous cavity in the 
body ; and the moderate admission of air into the pleural cavity, when 
the pleura is healthy, does not, as a rule, produce any ill effect. Thus in 
the London Lancet, January 15, 1831, the case is related of a man who 
suffered from heart disease, and was led to think that the pressure of a 
small amount of air internally might be substituted for external pressure, 
which always gave relief. He was his own instrument-maker and opera- 
tor. He constructed a small tube about as slender as a common pin, to 
which a bladder was attached filled with air. The point of this was 
thrust through an intercostal space till it penetrated the pleural cavity, 
and air was made to enter by compressing the bladder. Relief always 
followed, and the patient's health improved. This treatment was contin- 
ued two or three years. Dr. Lizars, who was present at the meeting of 



TREATMENT. 625 

the Medical Society before which this case was related, stated that he 
had performed a similar operation on four or five patients affected with 
aneurisms, with some apparent benefit, and in no case with injury. 

But the condition is very different if there be inflammatory products in 
the cavity. It is a fact known to all observers that animal liquids with- 
drawn from the circulation, and escaped from the vessels through injury 
or disease, remain in a closed cavity for a lengthened period without 
putrefactive change, as for example a clot of blood under the scalp or 
pericranium of a new-born infant ; but if air be admitted, it becomes 
offensive within a few hours. The admission of air into the pleural cav- 
ity which contains exuded products undoubtedly promotes putrefactive 
changes in the latter, and the admission of even a small amount of air, 
containing, as it does, micro-organisms, which multiply rapidly in the 
animal fluids, and which appear to be the active agents in putrefaction, 
suffices to convert sero-fibrin, or laudable pus, into an offensive, irritating, 
and poisonous liquid, which increases the constitutional disturbance and 
the gravity of the disease. 

Air in the pleural cavity, in proportion to its quantity, also tends to 
prevent the approximation to each other of the pleural surfaces and the 
obliteration of the cavity, which is required in all empyemic cases, since 
it is the mode of cure. Obviously the entrance of air does less harm if 
there be a fistulous opening and pus escape as soon as it forms, than in a 
closed cavity, but it should, in all instances, be avoided, as never benefi- 
cial, and likely to do harm in the manner indicated. It is never a neces- 
sary accident of thoracentesis, since it can be avoided by the use of 
proper instruments provided with India-rubber packing and stop-cocks. 
There can be no doubt, also, that the point of the aspirator has often so 
pricked and torn the lung, that air has entered the cavity from this organ 
— a result avoided by judiciously using the trocar and canula. 

2d. The lung is sometimes injured by the point of the hypodermic 
needle, employed for diagnosis. Cases are recorded in the hospitals of 
New York, of the breaking off and loss of the needle in the lung, from 
sudden and strong movement of this organ, as in coughing. The most 
severe injury is, however, commonly produced by the aspirator needle, 
and some very serious cases of this accident have occurred, in which the 
needle so pierced and tore the lung that not only air escaped from it, but 
also a considerable quantity of blood. It is obvious that the danger of 
injuring the lung is greater in recent than in chronic cases, and greater in 
sero-fibrinous than in purulent pleuritis, for a thickened, infiltrated, and 
firm pleura affords protection to the liing. It is very difficult to avoid 
injuring this organ if suction be made and the liquid be withdrawn with 
the unguarded point of the aspirator needle projecting into the chest. 
The removal of the liquid necessitates the impinging of the lung upon the 
point of the instrument even if it be held very obliquely, and in recent 
40 



626 PLEURITIS. 

cases, when there is little thickening and infiltration of the pleura, the 
surface of this organ may be pricked or torn sufficiently to allow air to 
escape, and hasmorrhage occur, when the operator who holds the needle 
can scarcely believe that such an accident were possible, so slight has been 
the sensation communicated to the fingers. Thus thoracentesis was per- 
formed on an infant of two months who had severe empyema of short 
duration. The instrument was held by myself obliquely, and it entered 
the pleural cavity only a short distance, and yet the lung was injured in 
three places, from which it was probable, from the signs and symptoms, 
that air had escaped. The specimen showing the injury was exhibited to 
the Pathological Society in 1879. Obviously, to prevent this injury, as- 
piration should be performed through the covered needle, as that of 
Phelps, or Potain's, or, which I have recommended above and prefer, the 
trocar. I must here repeat what has been stated above, not to plunge the 
trocar to a greater depth than is needed, w T hich is about one inch. The 
end of the canula may also injure the lung if it be pressed too deeply in r 
since it is necessarily rather sharp from its small size. 

3d. Washing out the Pleural Cavity. — Since the aspirator has come 
into general use, it is the common practice to wash out the pleural cavity 
with carbolized water in the treatment of empyema. The proportion of 
carbolic acid to water commonly employed is about one part to eighty, 
and at a temperature of 100°. From a discussion at the meeting of the 
New T York Surgical Society, Oct. 12, 1880, it appears that the use of car- 
bolized water involves risk of carbolic-acid poisoning in case the liquid be 
only partially removed after it is thrown into the pleural cavity, and Prof. 
Erskine Mason has for some time been in the habit of employing salicylic 
acid, one part to one hundred of water, in place of carbolic acid, as it 
possesses all the advantages with none of the possible risks of the latter. 
He states that it promptly deodorizes fetid pus even in the proportion of 
one part to two hundred. The use of carbolic acid would probably be 
entirely safe if the liquid were removed immediately after washing the 
cavity, but for some reason this is not always possible. In case of an 
infant with empyema under treatment by Drs. Lockrow, Billington, and 
myself, after removing the pus by trocar and canula attached to the ex- 
hausting-bottle, and once washing out the pleural cavity, the liquid was 
thrown in a second time, § iij into the left pleural cavity of an infant of 
five months, but not a drop of it could be removed. There was, how- 
ever, no symptom which we could refer to the carbolic acid. In view of 
these facts, and the possible danger of carbolic-acid poisoning, the use of 
salicylic acid appears to be preferable, at least for children, who are less 
able to resist the action of poisonous agents than adults. 

In this connection I must state my conviction that washing out the 
pleural cavity is unnecessary if empyema be treated as recommended 
above, and is apt to be injurious except in those cases in which the pus 



TREATMENT. 627 

has undergone decomposition, is offensive to the smell, and therefore 
poisonous. If it be putrid, its immediate disinfection as well as removal 
from the pleural cavity appear to be clearly indicated, but in the common 
form of empyema, as the pus escapes through the opening which has 
been made, and the suppurative cavity becomes smaller, adhesions of the 
pulmonary and costal surfaces occur, which the injection of water is apt 
to tear up and destroy, and thus the obliteration of the cavity is retarded. 
Letting out the pus and approximation to each other of the pleural sur- 
faces are the indications as regards surgical measures. Besides washing 
out the pleural cavity is not devoid of danger. Alarming symptoms may 
be developed unexpectedly and rapidly, even when the operation is slowly 
and cautiously performed. The infant of five months, with empyema, 
whose case I have alluded to, furnished a striking example of this. Four 
ounces of pus had been removed through a small canula from the left 
pleural cavity, and without removing the canula the cavity had been once 
washed out. It was proposed to repeat the washing, as the infant had 
thus far tolerated the operation, and was in an unusually favorable state 
for a case of empyema. The patient was in a semi-erect position, and 
three ounces of water at a temperature of 100° had entered the cav- 
ity from the inverted bottle, when he began to cough, fretted, and be- 
came very restless. Immediately Dr. Lockrow applied the suction-point 
of the syringe to the tubing, and attempted to withdraw the liquid, but 
with no result. The patient's face assumed a deadly pallor, he frothed 
at the mouth, his lips were compressed, and breathing ceased. He was 
to all appearance dead. He was immediately placed upon the back by 
Dr. Billington, and by prompt resort to artificial respiration, the terrible 
suspense was soon ended by the gasps of the child, and the return in a 
few moments of consciousness and normal respiration. It seemed to me 
that this untoward accident was due to the flow of water against the 
heart, so that it prevented full dilatation of its cavities, and, consequently, 
diminished the flow of blood into the aorta and produced anaemia of the 
brain. Lichtenstern says : " Various causes, which sometimes quite in- 
terrupt or impede the flow of blood to the left heart, such as severe par- 
oxysms of coughing, vomiting, lifting heavy burdens, may give rise to a 
suddenly fatal anamiia of the left heart, and secondarily of the brain. 
The anaemia of the lungs or brain found in many cases is only of second- 
ary importance. It frequently happens after thoracentesis with aspira- 
tion that an anaemia is produced in the partially distended lung, and this 
may lead to death by asphyxia. In sudden death during, or immedi- 
ately, or a short time after thoracentesis by aspiration, the cause is 
anaemia either of the heart or brain. In cases in which severe syncope 
and sudden death are observed during the irrigation of the pleural cavity, 
the cause is either direct mechanical concussion of the easily exhausted 
heart, by the stream of water thrown in, or shock." {Deutsches Archiv 



62S PLEURITIS. 

fur Klin. Med., Band IV., 4 Heft. Lond. Med. Record, Dec. 15, 
1880.) 

4th. The Use of Tent and Drainage Tube in Empyema. — "With due 
regard for the opinions of the experienced surgeons who employ and 
recommend the tent and drainage tube, but whose observations have been 
largely upon adult cases of empyema, I cannot recommend their employ- 
ment for children, unless perhaps the tent for a day or two after the in- 
cision ; but the tent is not necessary if the catheter be daily introduced 
in the manner which I have advised. The drainage tube almost necessa- 
rily admits air during inspiration, but this is not the most serious objec- 
tion to it. Cachectic children with poorly nourished tissues badly tole. 
rate pressure upon an open wound by a hard substance. It is apt to 
cause ulceration and enlarge the opening, and continued pressure of the 
tube is apt to cause periostitis upon the edge of the rib and necrosis. 
Scrofulous and feeble children are very prone to both caries and necrosis 
from even slight pressure or bruises upon the surface of the bone — a re- 
sult to which adults are much less liable. In a paper published by Mr. 
W. Thomas, in the Birmingham Med. Bee, 1880, N. S., vol. iii., on 
the treatment of empyema by resection of one or more ribs, nine cases 
are detailed, in three of which necrosis had occurred from pressure, it is 
stated, of drainage tubes, thus necessitating the removal of the diseased 
portion. During the last six months, a wasted empyemic infant was 
brought to one of the institutions of this city for treatment. After let- 
ting out the pus, a drainage tube was introduced and secured. At the 
next visit ulceration had so enlarged the opening that a large amount of 
air entered the chest with a whistling noise at each inspiration, and was 
expelled during expiration, and necrosis of the portion of the rib against 
which the tube pressed had also occurred. Air was finally excluded by 
covering the opening w T ith a cloth smeared on each side with a concen- 
trated solution of gutta-percha in chloroform, but the case after some 
days ended fatally. The escape of the drainage tube into the pleural cav- 
ity, which has occurred by breaking of the threads which secured it, is 
so rare an accident that it does not constitute an objection to the intro- 
duction of the tube ; but aspiration daily or twice daily through the 
catheter so completely removes the pus that drainage is not required, and 
the risk of injury by the pressure of the tube is therefore avoided. 

5th. I have witnessed, in a few instances, the burrowing of pus under 
the skin at the point where an incision had been made to let out the pus. 
This complication may lead to more or less ulceration or sloughing, and 
it greatly increases the danger of poisoning. But infiltration of pus will 
almost never occur if the incision be direct through the tissues and not 
with the skin pushed one side, so that it forms a covering or valve when 
it returns, as was once recommended in the books as a means of exclud- 
ing air. But air does not enter the cavity through a direct opening if it 



TREATMENT. 629 

be properly covered after the pus has escaped. Burrowing of pus and 
pyemic poisoning therefrom cannot then be regarded as an accident of 
the mode of operation which I have recommended. 

Exsect'wn of a Portion of one or more Ribs. — This operation has 
now been performed a considerable number of times in Europe and in 
this country, and, from the published accounts, certain cases have appar- 
ently recovered more rapidly in consequence. Thus in one case a fistu- 
lous opening, spontaneously established, had continued several months, 
with little diminution in the discharge, and very slow progress toward 
recovery, when by this operation, which produced a larger opening and a 
freer escape of pus and falling of the chest-wall, so as to obliterate the 
cavity, the patient rapidly convalesced. 

The alleged benefit from the exsection, which consists in the removal 
of an inch or a little more of one or more ribs, in or near the site for the 
usual performance of thoracentesis, is, that there is a readier escape of 
pus and the facility for washing out the pleural cavity is increased, and 
the thoracic wall and lung more readily approximated so as to produce 
obliteration of the pleural cavity. The greatest benefit is claimed for it 
in those cases in which the intercostal spaces are small and the ribs lie 
close to each other. 

Without denying that certain cases have apparently been benefited by 
the operation, I must say that I have not yet met a case either in family 
or hospital practice, in which I could conscientiously recommend tin' 
operation, except where necrosis had occurred from a periostitis produced 
by the irritating property of the pus, or the pressure of a drainage tube. 
The gum-elastic catheter, introduced as recommended above, will pass 
through any intercostal space which I have yet observed, so as to allow 
free evacuation of the pus by suction, if it be not incapsulated by fibrin- 
ous bands, and allow also the free washing out of the pleural cavity if this 
be desired. 

There are also serious objections to the exsection in case of a child. 
The svstem, exhausted by a suppurative inflammation, is in poor condi- 
tion to tolerate an operation of any severity, and although we are directed 
to preserve as far as possible the periosteum from injury by the knife, 
and be careful not to wound the intercostal vessels, there are necessarily 
more or less shock and hemorrhage and consequent danger of hastening 
the death of the patient. In one of the cases, that of an infant, reported 
by an advocate of the operation, it seems to me that death was largely 
attributable to the exsection. 

In order tha'<, exsection aid materially in the approximation of the lung 
and ribs, it is necessary to remove portions of two or more ribs, and 
the greater the operation the greater the risk. But what is needed is not 
depression of the ribs, which may produce permanent deformity, but ex- 
pansion of the lung, and this is promoted by the integrity and resiliency 



630 NEKVOUS COUGH. 

of the ribs. Therefore, in my opinion, a reaction will take place in the 
professional mind against this operation. 

Nervous Cough. 

A nervous cough sometimes occurs in children, especially between the 
ages of two or three and ten years. Tt may result from disease of the 
brain, from the second as well as first dentition, from some irritant in the 
intestines, as worms, and also from spinal irritation. Occasionally there 
appears to be no local cause, but a state of anaemia, or a highly developed 
nervous temperament, to which it seems proper to ascribe the cough. 
Occurring under these last circumstances it corresponds with, and is some 
times accompanied by, functional disturbance in the action of the heart, 
as palpitation. 

A nervous cough is short, painless, and without expectoration. It 
usually attracts little attention at first, but from its long duration the 
friends finally become anxious lest it betoken some serious disease. At 
times it may nearly subside if the patient lead a quiet life and the general 
health improve, and there are periods of recrudescence if the opposite 
conditions obtain. It may have a spasmodic character, especially in times 
of mental excitement, but in a less degree than the cough of pertussis. 
If not properly treated, it usually continues several weeks or months, dis- 
appearing as the general health and the tone of the nervous system im- 
prove. It is not in itself a serious disease, nor does it lead to any ailment 
or produce any injury of the respiratory organs, but it is an unpleasant 
malady, and is liable to be mistaken for incipient tuberculosis if it occur 
in one decidedly cachectic, and belonging to a family predisposed to 
phthisis. 

Treatment. — If there be a local cause of the cough, measures calculated 
to remove this, or at least to palliate its effects, are obviously required. 
Especially should constipation, or any abnormality in the digestive func- 
tion be corrected. But in many cases there is no apparent local ailment 
which produces the cough by its irritative effect, and the remedial meas- 
ures must then be twofold, namely, measures designed to improve the 
general state, and, secondly, measures designed to relieve the cough. 
Such measures are also required in most cases in which there is a local 
cause, provided that the cough do not cease when treatment calculated to 
remove this cause has been employed. 

For constitutional treatment no remedy is so useful in ordinary cases as 
iron. The following example shows the benefit which may result from 
the use of this agent, since in this case it effected a cure without the aid 
of other measures. B — , aged 11 years, pallid and of spare habit, but 
active, and with good appetite, had been treated for this malady by 
different physicians but without improvement. His mother had died of 



TREATMENT. 631 

tuberculosis, and some at least of the physicians believed that he was in 
the commencement of the same disease. Finally he was placed under the 
■care of the late Dr. Cammann, who, detecting the nature of the malady, 
wrote the following prescription : 

9. Ferri. subsulphat., 3 ss ; 
Acid, nitric, f 3 ss. 
Aq. destillat., 3 ss. Misce. 
Dose, three drops four times daily in sweetened water. 

The cough disappeared in a surprisingly short time. If the appetite be 
poor the vegetable tonics are required in combination with iron. 

If the cough be frequent and troublesome, medicines which exert a 
direct controlling effect upon it are required in addition to the medicines 
and measures employed to improve the general state. For this purpose 
no remedy is so useful as the bromides, emploved alone or in combination 
with belladonna. If there be no decided anaemia, and no local cause of 
the cough, the bromides and belladonna usually effect a cure without the 
employment of constitutional measures, or if the case seem to require 
iron it may be given in the interval. The following is the prescription 
for a child of three years : 

t£. Tinct. belladonnae, gtt. xxxij ; 
Potas. bromid., 
Amnion, bromid., aa 3 j ; 
Syr. simplic, ^ij. Misce. 
Dose, one teaspoonful twice daily. 

In 1871 I was asked to prescribe for a German boy, aged 8-J- years, who 
had a cough of this kind of two months 1 duration, which latterly had 
been frequent and annoying. Within a week he was entirely relieved 
without other remedy, by the employment of tincture of belladonna, 
drops v, and bromide of ammonium, gr. v, twice daily. Outdoor exer- 
cise, or country residence, and other regimenal measures which improve 
ithe general health, are useful in ordinary cases. 



SECTION III. 

DISEASES OF THE DIGESTIVE APPARATUS. 



CHAP TEE I. 



SIMPLE STOMATITIS, ULCEROUS STOMATITIS, FOLLICULAR STOM- 
ATITIS. 

Diseases of the digestive system are very frequent in infancy and 
childhood. They are for the most part readily recognized, and are more 
easily and quickly controlled by therapeutic agents, if rightly applied, 
than are the diseases of any other system. If misunderstood and im- 
properly treated, they may, even when mild and very manageable in their 
commencement, become chronic and obstinate, or even fatal, or they may 
lead to other and more dangerous diseases. It is necessary, then, that 
the physician should understand thoroughly the pathology as well as 
therapeutics of the digestive system, that he may make timely and cor- 
rect use of the required remedies. 

The diseases of the buccal cavity in early life are for the most part in- 
flammatory. The mildest is that known as 

Simple or Catarrhal Stomatitis. 

This form of catarrh occurs usually before the completion of first denti- 
tion, and it is most frequent under the age of one year. Ghing rise in 
itself to no severe symptoms, and often being connected with other grave 
and dangerous maladies, it is, doubtless, in many cases overlooked. It is 
sometimes confined to a portion of the buccal surface, or is more intense 
in one part than in another. In other cases the catarrh is uniform, or 
nearly so, affecting the entire cavity of the mouth. 

Causes. — The common cause of simple stomatitis in infants is the same 
as that of most cases of gastro-intestinal inflammation at that age. This 
is the use of indigestible and therefore irritating food, un cleanliness, per- 
sonal and domiciliary ; in fine, all those agencies which impair the gen- 
eral health, and enfeeble the digestive organs. Therefore, stomatitis, like 
enteio-colitis, is more common in the city than in the country, and 
among the city poor than those in the better walks of life. Infants de- 



SYMPTOMS — APPEARANCES — TREATMENT. 633= 

prived of the mother's milk, and given a diet which, with all care of 
preparation, is a poor substitute for the natural aliment, are very liable to 
this disease. Beaumont ascertained from his experiments on St. Martin 
that irritative changes produced in the stomach by indigestible substances 
were soon followed by similar changes in the buccal mucous membrane. 
Since in young infants any kind of artificial food is less digestible than 
the breast milk, it is evident why those who are prematurely weaned or 
are carelessly fed are so liable to stomatitis. This inflammation is also 
sometimes due to irritating substances taken in the mouth, as drinks 
habitually too hot or too cold. Stomatitis is also present in measles and 
scarlet fever. It then corresponds with the cutaneous eruption, and dis- 
appear when that subsides. 

Another cause is dentition. The gum over the advancing tooth first 
becomes inflamed, and, other causes perhaps conspiring, the inflammation 
extends over more or less of the buccal surface. When due to dentition 
the stomatitis is more apt to be partial than when it arises from a consti- 
tutional cause. Mercury, in whatever form introduced into the system, 
excreted from the salivary glands, and flowing over the buccal surface, is 
an occasional though nowadays rare cause. 

Symptoms — Appearances. — Stomatitis, like other mucous inflamma- 
tions, is characterized by increased redness and more or less thickening 
of the inflamed buccal membrane, by rapid proliferation and exfoliation 
of epithelial cells, and by an increased functional activity of the mucipa- 
rous follicles. The heat of the mouth is sometimes augmented in an ap- 
preciable degree. The gums in severe cases are swollen and spongy, and 
bleed easily if rubbed or pressed. The tongue is usually covered with a 
light fur, and the salivary secretion is augmented to such an extent some- 
times as to dribble from the corners of the mouth. Often there is little 
suffering, but in other instances the patients are fretful, experience pain 
from the contact of solid food, and, if nursing, may even wean them- 
selves from dread of pressure of the nipple. 

Simple stomatitis is not difficult of detection, provided that attention 
be directed to the mouth. Inspection informs us of its presence and 
extent. A favorable termination may be confidently predicted, unless there 
be a state of marked cachexia, or a grave coexisting disease. If circum- 
stances are unfavorable, simple stomatitis may terminate in a more severe 
form, as the ulcerous or diphtheritic. 

Treatment. — The physician should endeavor to ascertain the cause, 
and, if possible, should remove it by appropriate medicinal or hygienic 
measures. Sometimes no special treatment is required, as in measles or 
scarlet fever. When the primary affection terminates, the stomatitis dis- 
appears of itself. If dentition be the cause, and there be much fever and 
fretfulness, it has been the common practice to scarify the gums, but this 
operation is in my opinion seldom advisable. A few doses of the bro- 



63-i ULCEROUS STOMATITIS. 

mide of potassium relieves the fretfulness, and mucilaginous and mild 
astringent lotions suffice for the catarrh. Borax is a good local remedy 
used either with honey or with glycerine and water; one part of borax to 
three of honey, or a drachm of borax to an ounce of glycerine and water. 
A weak solution of alum is also a useful topical remedy. With either of 
these agents in a favorable condition of system, and without any seri- 
ous coexisting disease, the stomatitis is relieved. 

Ulcerous Stomatitis. 

In ulcerous stomatitis, the anatomical characters are those of severe 
simple stomatitis, with the additional element which gives it the name 
by which it is designated. 

The inflammation usually begins upon the gums and extends along 
the buccal surface. Little white points soon appear upon the under 
surface of the mucous membrane, producing slight prominence of it. 
These points, which are inflammatory exudations, mainly fibrinous, grad- 
uallv enlarge. Some unite and give rise to large irregular ulcerations : 
others remain isolated, producing ulcers which are smaller and of more 
regular shape. There is, indeed, no uniformity as regards the size and 
form of the ulcers. In the folds of the buccal membrane they are apt to 
be elongated, while inside the lips, or where the surface is smooth, the 
circular or oval form predominates. It is a noteworthy fact that the ex- 
udation underlies the mucous membrane, obstructing its nutrient vessels, 
so that the ulcer which results causes destruction of the mucous layer, and 
cure is effected by cicatrization. 

Ulcerous stomatitis is usually confined to that part of the buccal surface 
which covers the gums, or is in their immediate vicinity, but in some in- 
stances it affects nearly every part of the cavity of the mouth. 

If the disease be severe, considerable swelling occurs around the ulcers, 
but the swollen part is soft and cushiony, and not very tender on press- 
ure. The soft and yielding nature of the swelling serves as a means of 
diagnosis between this disease and the premonitory stage of gangrene, 
since in the latter affection the swollen part is more indurated. 

If the disease grow worse, more ulcers appear, and those already pres- 
ent grow deeper and wider, and their edges more vascular. 

If, on the other hand, there be improvement, the swelling subsides, the 
ulcers become more clean, their bases approach the level of the mucous 
membrane, and present a granulating appearance. Finally the mucous 
layer is reproduced. A considerable time after the ulcers are healed, the 
new membrane which occupies their site has a redder hue than the adja- 
cent surface. 

Causes. — Ulcerous, like simple stomatitis, is most frequent in the fam- 
ilies of the poor. Personal un cleanliness, poor food, a residence in 



SYMPTOMS — PROGNOSIS — TREATMENT. 635 

apartments dirty, humid, or in other respects insalubrious, favor its de- 
velopment. In fine, a cachectic condition, however produced, is a com- 
mon predisposing cause. It frequently occurs when the system is reduced 
or enfeebled by acute diseases, as after the essential fevers and thoracic 
and intestinal inflammations. In protracted entero-colitis of infants, it is 
sometimes severe and obstinate, and a case in which this complication 
arises usually ends unfavorably. The abuse of mercury is an occasional 
cause of this form of stomatitis, as well as of simple catarrh. Jaccoud 
states that Bergeron established the fact that ulcerous stomatitis is propa- 
gated among soldiers by contagion, and he adds " it is very probable that 
it is the same in infants." 

Symptoms. — The symptoms in ulcerous stomatitis are more severe than 
in the simple form. There are more pain, more salivation, and more fret- 
fulness. The ulcerated surface is sometimes very tender, so that there 
is but little sleep. Drinks, unless bland and lukewarm, are painful, and, 
if the ulcers be on the lips or the front of the mouth, the infant nurses 
less eagerly than usual, and even with reluctance, sometimes weaning 
itself. Occasionally the submaxillary glands are tumefied, hard, and ten- 
der. The breath has an offensive odor. In mild cases, in which the 
stomatitis is of limited extent, this odor may scarcely be noticed, but 
in severe cases it is almost like that exhaled from putrid substances. The 
febrile movement is usually slight. 

Prognosis. — A favorable prognosis may be given unless the patient be 
in a decidedly cachectic condition, or there be a serious coexisting disease, 
under which circumstances the case may be protracted. If death occur, it 
is due to the cachexia, or to some pathological state quite distinct from 
the stomatitis, most frequently entero-colitis. Ulcerous stomatitis, when 
the ulcers arc small and the inflammation of limited extent, is of course 
more easily cured than when it is extensive and the ulcers are large. 

This disease is very liable to return, unless the general health be good. 

Treatment. — The physician should endeavor to ascertain the cause of 
the stomatitis, and as far as possible should remove the patient from its 
influence. It is often necessary, in order to insure a speedy recovery, to 
recommend a change in regimen, especially as regards diet and cleanli- 
ness. If the patient live in damp, dark, and dirty apartments, the family 
should seek a better residence, and he should be taken daily in the open 
air. 

Tonic remedies are generally required. The ferruginous preparations 
may be advantageously given, or the vegetable tonics, or the two in com- 
bination. In selecting the internal remedies we must regard the antece- 
dent disease, if there be any, which the buccal inflammation complicates, 
and on which it depends. For that large proportion of cases in which 
there is chronic intestinal inflammation, the liquor ferri nitratis with tinc- 
ture of Colombo administered in simple syrup will be found useful. For 



636 APHTHOUS STOMATI T I S . 

local treatment Trousseau recommends occasional applications of nitrate 
of silver or muriatic acid as a caustic, and in the intervals a wash of 
equal parts of borax and hone)". 

The chloride of lime is also considerably used in Paris. It is recom- 
mended by Rilliet and Barthez. It is applied dry to the ulcerated surface 
twice daily, and in the interval the mouth is washed with simple water. 
This treatment is continued till the ulcers present a healthy appearance 
and begin to cicatrize. Then a weak solution of chloride of lime is em- 
ployed, one grain to forty-five of the vehicle. By this treatment a cure 
is usually effected. Bouchut prefers using chloride of lime with honey, 
one drachm to the ounce. 

But painful applications are not required. The remedy which is most 
employed in this country and in Great Britain is chlorate of potassium. 
It often acts like a specific for this as well as other forms of stomatitis. 
It may be given dissolved in water with sugar, or with one of the syrups, 
to render it more palatable. The dose is about two or three grains every 
two hours. It should be allowed to run over the affected part, as it is 
believed to have a local action. 

£. Potass, chlorat. , 3 ss-j ; 
Mellis, 5 ss ; 
Aquae, |ij. 
One teaspoon ful every two liours. 

Of all topical remedies in common use, chlorate of potassium is proba- 
bly the most efficacious. Some physicians prefer the chlorate of sodium, 
on account of its greater solubility. If this wash be too painful in con- 
sequence of the irritable state of the ulcers, it may be mixed with mucilage 
or less frequently used, and borax applied in the interval. 

Aphthous Stomatitis. 

Aphthous stomatitis may occur at any age, but it is most frequent in 
childhood. It is sometimes designated follicular stomatitis, but the dis- 
ease affects the contiguous mucous surface, as well as the seat of the 
follicles. At first a vascular injection is observed, and within a few hours 
a whitish exudation occurs immediately under the epithelium, and upon 
the corium, in small round or oval isolated spots. The smallest of these 
patches are not larger than a pin's head, but most of them have a di- 
ameter of one to two lines, and they cause slight prominence of the sur- 
face. In two or three days the exudation softens ; and the epithelium, 
which covers it is thrown off, producing an ulcer, superficial, without 
induration of its edges, but sensitive to the touch. It heals in one to 
two weeks, leaving only a reddish spot or stain, which soon fades. Some- 
times two or more aphthae unite, forming a patch, and an ulcer of corre- 



CAUSES — TREATMENT. 637 

spondingly large size. The seat of aphthous stomatitis is usually the 
internal surface of the lips and cheeks, the gums, tongue, and occasionally 
the roof of the mouth. 

Causes. — Probably in most instances the exciting cause is some de- 
rangement of the digestive organs, which may not be appreciable. We 
sometimes observe it in cases of diarrhoea. Occasionally, especially in 
spring and autumn, two children in a family are affected at the same 
time, or two or more in a school, so that it presents an epidemic charac- 
ter. Children surrounded by bad hygienic conditions, as in the tenement 
houses of the cities, are more liable to this as well as other forms of stom- 
atitis, than are children who live in clean and airy localities, and have 
nutritious and wholesome diet. 

Symptoms. — The constitutional symptoms in a large proportion of cases 
of aphtha) are slight. In twelve children affected with this disease Billard 
found the pulse from sixty to eighty beats per minute. 

The ulcers are painful, as is indicated by the cries of the child when 
they are pressed, and its fretfulness. Solid food and even drinks, unless 
bland and unirritating, are badly tolerated. The salivary secretion is also 
augmented. 

In those rare cases in which the ulcer becomes confluent or gangrenous, 
the state of the patient is really serious. There is then often gastrointes- 
tinal disease. The symptoms indicate prostration. The pulse is feeble, 
the countenance pallid, and the body and limbs become wasted. 

Diagnosis. — This is easy. The only disease with which it is liable to 
be confounded is ulcerous stomatitis. In the ulcerous form there is ante- 
cedent and accompanying stomatitis affecting a considerable part, if not the 
entire buccal cavity, while in the follicular form the inflammation is ordi- 
narily confined to the immediate vicinity of the ulcers. The character of 
the ulcers serves also as a means of distinction. In ulcerous stomatitis 
there is great variety as to size and form, while in aphthous stomatitis 
there is great uniformity in both these respects. The small, circular 
ulcers are characteristic of the follicular inflammation. Before the ulcer- 
ative stage the circumscribed character of the eruption serves to distin- 
guish this form of stomatitis from other local diseases affecting the cavity 
of the mouth. 

Prognosis. — Aphthous stomatitis usually ends favorably; but, if the 
ulcers become concrete or gangrenous, the health is seriously affected, 
and a more cautious prognosis should be expressed. The unhealthy ap- 
pearance of the mouth and the real danger are often more due to the 
depressing effect of some concomitant disease than to the stomatitis. 

Treatment. — In ordinary aphthous stomatitis, which is discrete and 
attended by little or no constitutional disturbance, local remedies suffice to 
cure the disease. Demulcent drinks or applications to the mouth should 
be used, as the mucilage from gum acacia, marsh-mallow, or flaxseed. 



638 THRUSH. 

Mild astringent lotions with the demulcent are also beneficial. The mel 
boracis is one of the best and most agreeable applications. It may be 
placed in the mouth with a spoon, or applied with a camel-hair pencil. 
If there be much tenderness of the ulcers, with restlessness, a small quan- 
tity of some opiate should be added to the lotion, or it may be adminis- 
tered separately. 

With this simple treatment the ulcers generally soon heal, and the 
health of the patient is restored. If, however, the ulcers be quite pain- 
ful, and not disposed to heal, or be healing tardily, they may be touched 
lightly with a pencil of nitrate of silver, or, as Barrier recommends, hydro- 
chloric acid in honey of roses. This diminishes the tenderness and expe- 
dites the healing process. 

If, as may in rare cases occur, the ulcerations be numerous, and 
accompanied by considerable fever, there may be symptoms indicative of 
cerebral congestion, or even premonitory of convulsions. In such cases 
laxatives and the soothing effect of one of the bromides and sometimes of 
the warm foot-bath are required. 

If there be an unhealthy appearance of the ulcers, if they gradually 
enlarge or become concrete, or gangrenous, indicating a cachectic state, 
tonics should be employed with nutritious and easily digested diet, and 
anti-hygienic influences should so far as possible be removed. 



CHAPTEE II. 

THRUSH. 

The terms thrush, sprue, and muguet, the last from the French, are 
synonymous. They are used to designate a particular form of inflamma- 
tion of mucous surfaces, the peculiar feature of which is the presence of 
points or patches of a curdlike appearance on the inflamed surface. 

The usual seat of thrush is the buccal membrane, but occasionally it 
affects the faucial, pharyngeal, or oesophageal surface. It is rare in the 
subdiaphragmatic portion of the digestive tube, but a few such cases have 
been reported by Billard and others. It never affects the membrane of 
the nostrils, larynx, or bronchial tubes, and it very seldom occurs in any 
other part of the alimentary canal without also being present in the 
mouth. Thrush, then, is a stomatitis, pharyngitis, or oesophagitis, or a 
gastro-enteritis, with the additional element which I have described. 

Anatomical Characters. — The first stage of thrush is that of simple 
inflammation of the mucous surface. There next appear minute semi- 
transparent points or granules, which, increasing, soon become white 



ANATOMICAL CHARACTERS. 639 

and opaque. Some of them remain as points, while others, extending, 
and perhaps coalescing with those adjoining, form patches of greater or 
less extent. The white points or patches are unequally elevated. Their 
central part, which was first formed, is most raised, while their circumfer- 
ence projects but little above the epithelium. Their highest elevation is- 
not ordinarily more than a line above the surface. They are smaller in 
the pharynx and oesophagus than when occurring upon the buccal surface. 
They resemble closely, in color and consistence, portions of curdled milk, 
and the nurse often mistakes them for such, and neglects to call attention 
to the state of the mouth. They are readily detached by a little force, 
but are speedily reproduced. Their color in the first days of the sprue is 
white, and sometimes this color continues. In other cases they assume, 
if the disease be protracted, a yellow hue. 

Their true nature, long unknown, was finally revealed by microscopy. 
They consist in part of epithelial cells, and in part of a vegetable growth. 
This parasitic plant is in most cases the oiidium albicans. Like other con- 
fervae, it consists of roots, branches, and sporules. The roots are trans- 
parent, and they penetrate the epithelial layer, sometimes even to the 
basement membrane. The branches divide and subdivide at an acute 
angle, and under the microscope they are seen to consist of elongated 
cells, with one or two nuclei. Around these branches are numerous spo- 
rules. In two or three instances I have examined the product of thrush 
removed from the oesophagus, and in both the parasitic plant was the 
penicillium glaucum, or a conferva closely resembling it. 

In the mildest form of thrush, this morbid product is in points or 
small patches. If the patches be of large extent, especially if, as rarely 
happens, a considerable part of the buccal surface be covered by them, 
there is generally a state of great prostration and danger, from some ante- 
cedent or concomitant disease. Thrush is, indeed, often the sequel of 
some grave affection, as pneumonitis or gastro-intestinal inflammation. 
Its complication with the last-named disease is common in young, ill-fed 
infants, especially those deprived of the breast-milk, and such cases are 
very apt to be fatal. 

Hence, some writers, who have observed infantile diseases in foundling- 
hospitals, regard thrush as one of the most serious maladies of early life. 
Valleix, in a book of seven hundred pages relating to diseases of children, 
devotes more than one third to the consideration of muguet. Of twenty- 
four cases, the records of which he publishes, twenty -two died, but their 
death was due to gastro-intestinal inflammation, which the author consid- 
ered a part of the more general disease, muguet. Doubtless the same 
cause which produced the stomatitis, with the confervoid growth, in these 
infants, also produced the fatal gastritis or gastro-enteritis, occurring 
without this growth. Nevertheless it seems better to restrict the term 
sprue, thrush, or muguet to those inflammations of mucous surfaces which 



640 THRUSH. 

are accompanied by the parasitic growth. I reject, then, from my descrip- 
tion of the anatomical characters of thrush, those subdiaphragmatic 
phlegmasias which some writers consider an important part of severe 
muguet, and regarded them as complications, unless indeed the case be one 
of those exceptional ones in which the parasite has lodged and grown 
upon the gastric or intestinal surface. This explanation seems necessary 
in order to understand the different statements of writers in relation, not 
only to the anatomical characters of thrush, but also in reference to its 
mortality. 

The frequent coexistence of thrush with gastro-intestinal inflammation, 
has been remarked in the hospitals of Europe, and in the Infant Asylum 
and the Child's Hospital, in this city. In the post-mortem examinations 
of those who have died in these last institutions, having thrush at the time 
of death or immediately prior to it, and who for the most part have been 
infants under the age of three months, I have frequently found evidences 
of inflammation in every division of the alimentary canal. The coufer- 
void growth was, however, seldom seen below the fauces, and never be- 
low the oesophagus. 

Symptoms. — The symptoms in thrush are not different in most patients 
from those of simple inflammation. In the mildest cases they are chiefly 
of a local nature, such as have already been described in our remarks on 
simple stomatitis. If the inflammation be more extensive, especially if it 
affect the fauces and oesophagus, the infant becomes feverish and fretful, 
and the inflamed surface is hot, red, and tender. In the worst forms of 
thrush this surface not only presents the ordinary features of severe in- 
flammation, namely heat, redness, and tenderness, but it is sometimes 
deficient in the natural secretion, so as to present a dry or parched ap- 
pearance. It is in these cases that there is often a more extensive inflam- 
mation than that of the buccal or oesophageal membrane. The sub-dia- 
phragmatic portion of the digestive tube is inflamed. In this severe form 
of sprue, thirst, loss of appetite, restlessness, vomiting, and frequently diar- 
rhoea occur. The countenance is anxious and pallid ; there is rapid emaci- 
ation, and, if the disease be not arrested, a state of extreme prostration 
soon arrives. The twenty -four severe cases related by Valleix, already 
alluded to, twenty -two of which were fatal, were examples of this severe 
form. 

Causes. — Thrush is most apt to occur in those who are constitutionally 
feeble, or who are enfeebled by disease, or by unfavorable hygienic con- 
ditions. Cachexia is a cause common to thrush and most other subacute 
inflammations of the alimentary canal. The most obvious and common 
of the unfavorable hygienic conditions alluded to is the continued use of 
indigestible and improper food. It is, therefore, a common disease 
among foundlings, in institutions where these unfortunates are received, 
since they not only breathe an atmosphere which is often impure, but are 



DIAGNOSIS — PROGNOSIS — TREATMENT. 641 

deprived of the mother's milk, and are so frequently given a diet which is 
a poor substitute for it. Among the destitute of the cities thrush is common, 
since with them, from necessity or choice, there is the greatest neglect of 
sanitary requirements. Exposure to humidity, to variations in tempera- 
ture, increases the liability to the disease, though in less degree than de- 
fective alimentation. Billard and Valleix agree that thrush is more fre- 
quent in the warm months than in the cold, that its maximum frequency 
is in the months of July, August, and September. Cases in the Infant 
Asylum and Child's Hospital of this city, have appeared to me to corre- 
spond in this respect with those related by Billard and Valleix. Various 
writers have mentioned the age at which thrush is most apt to occur, as one 
of the predisposing causes. Uncomplicated thrush is not common above 
the age of six months. Most cases occur under the age of three months. 
Infants of the age of one or two weeks, if in addition to lactation they 
are spoon-fed by nurses over-anxious that they should thrive, are apt to 
take the disease. Thrush is not uncommon in children under the age of 
eighteen months who are suffering from exhausting diseases. It is then 
an unfavorable prognostic sign. 

Diagnosis. — This is easy so far as thrush in the mouth is concerned, 
for simple inspection by one familiar with the disease is all that is required 
in order to discover it. The presence of thrush in portions of the ali- 
mentary canal hidden from view cannot be positively ascertained. 

The vomiting, diarrhoea, pain or fretfulness, emaciation, and rapid 
sinking, which sometimes accompany severe forms of thrush, indicate 
gastro -intestinal inflammation, to which the attention of the practitioner 
should be chiefly directed. 

Prognosis. — The duration of thrush varies according to its intensity, 
and the favorable or unfavorable condition of the child. If it be slight 
and the health of the infant otherwise good, it may often be cured in two 
or three days. Under other circumstances it may continue as many 
weeks or even longer, before it is entirely removed. 

When thrush occurs in connection with gastro -enteritis, the mortality 
is very great. It has been already stated that in Valleix's twenty-four 
cases twenty-two were fatal. M. Auvity estimates the mortality of such 
cases at nine in ten, and M. Godinat at two in three. 

Treatment. — As one of the most common causes of thrush is the use 
of indigestible or improper food, the physician should ascertain the 
nature of the infant's diet, and if it be faulty, should direct a better. In 
many cases the infant is bottle-fed. It should be given only the moth- 
er's milk if practicable, or that of a healthy wet-nurse. This change of 
alimentation often removes the sole cause of thrush in the young infant, 
so that it rapidly recovers. 

If artificial feeding be necessary, such diet should be advised as is 
directed in our remarks on the treatment of the diarrhoeal maladies. 
41 



642 THRUSH. 

There is often in thrush an excess of acidity in the digestive tube, and an 
alkali is required. Trousseau recommends the addition of saccharate of 
lime to the milk. Children with this disease should also be taken from 
filthy and damp apartments, to those in which the air is pure and dry, 
and their mouths and persons should be kept clean. 

The remedy in common use in the treatment of thrush, and which is 
usually effectual, is borax. This, if applied sufficiently often to the affect- 
ed membrane, not only destroys the parasitic growth, but prevents its 
reproduction. It is commonly employed with honey, or in a powder 
with sugar or dissolved in water. The officinal mel boracis, consisting of 
one part of borax to eight of honey, is so much used in families that it 
may be considered almost a domestic remedy. There is, however, an 
objection to using any application for the removal of thrush which con- 
tains either sugar or honey, since either substance remaining in the mouth 
would rather promote the growth of the parasite. Still, it is desirable to 
employ a wash of such consistence that it will remain a longer time in 
contact with the buccal surface than will a simple solution in water. I 
know no better vehicle for the borax than glycerine, which has the advan- 
tage of consistence, does not undergo any chemical change, and has no 
unpleasant flavor. The borax may be used dissolved in glycerine, with or 
without some flavoring ingredient : 

B. Sodii borat., 3j ; 
Glycerinae, 3 ij ; 
Aquse. 3 vj. Misce. 

Borax should be used four or five times daily, and continued for a time 
after the disease has disappeared from sight, since the roots of the plant 
must be destroyed or the branches are rapidly reproduced. It should be 
applied by a camel-hair pencil, or with a soft cloth upon the finger, or a 
stick. It should be so freely used, in extensive and severe forms of the 
disease, that the infant will swallow some, since the entire oesophagus is apt 
to be affected in such cases. In the intervals between the applications of 
borax, if the buccal surface be hot, dry, and tender, so as to increase the 
fretfulness of the infant, it is well to use mucilaginous washes, as the 
mucilage of acacia or mallows. If the disease continue notwithstanding 
the use of these measures, the mouth should be occasionally washed with 
a weak solution of nitrate of silver or sulphate of zinc : 

B. Zinci sulpb., gr. ii-iv ; 
Aq. rosse, §ij. Misce. 

In many cases, however, the treatment of thrush is of less importance 
than that of the disease which the thrush complicates. The remedial 
measures which I have mentioned then become subordinate to those em- 
ployed for the graver disease. When this disease is relieved and the gen- 
eral health improves, thrush is more easily and permanently cured than 
during the state of feebleness and ill -health. 



GANGRENE OF THE MOUTH. 643 



CHAPTEK III. 

GAXGBENE OF THE MOUTH. 

The diseases of the mouth which we have been considering are attend- 
ed by little danger, but the one which we are next to consider is anions,* 
the most fatal of early life. It is gangrene of a portion of the cheek or 
gums, or of both. It is described by writers under various names, as 
cancrum oris, noma, necrosis infantilis, aqueous cancer of infants. 

Anatomical Characters. — Gangrene of the mouth is sometimes pre- 
ceded by ulceration of the mucous membrane, at the point where it is 
about to commence, but in other cases this membrane is entire. The tis- 
sues at the point of attack, which is most frequently the inside of the 
cheek, become inflamed, thickened, and indurated. The induration ex- 
tends, and soon the purple hue of gangrene appears and increases. The 
next stage in the progress of gangrene is sloughing of the portion the 
vitality of which is lost. 

The slough does not present the appearance of uniform decay. While 
the color is generally dark, there are in the mass fibres of connective tis- 
sue, or even bloodvessels which remain unchanged or are but partially de- 
composed. After separation or sloughing of the part where the vitality 
is first lost, the surface of the excavation, if the disease be not checked, 
has a dark, jagged, and unhealthy appearance. Commencing with the 
mucous membrane and the tissue immediately underlying it, the disease 
extends on the one side toward the skin, and on the other toward the 
deeper seated structures of the jaw. According to Billard, the swelling 
which precedes and surrounds the gangrene is in great part cedematous. 

This disease is occasionally primary, but in a large proportion of cases 
it is secondary. Occurring secondarily, its symptoms are often masked 
by those of the antecedent and coexisting affection. Under such circum- 
stances attention is sometimes first directed to the mouth, by the loosen- 
ing of one or more of the teeth, or the appearance on the skin of a livid 
circular spot, which indicates the approach of the disease to the cutaneous 
surface. The mucous membrane presents a dark-red appearance to the 
distance of a few lines beyond the point of gangrene. It covers tissues 
which are inflamed and indurated and about to become gangrenous. 

The tongue is usually more or less swollen, unless the disease be mild ; 
an offensive odor arises from the gangrene, due to the evolution of sul- 
phuretted hydrogen and other gases. There is great difference in the ex- 
tent of the destruction, and the gravity of the disease, in different cases. 



< )44 GANGKENE OF THE M OUTH. 

It may sometimes be arrested by proper applications and a favorable 
change in the general health of the child at an early period, when there is 
little loss of substance. In other cases it extends till it perforates the 
cheek, or even destroys a considerable part of the side of the face, and, 
extending inward, attacks the periosteum of the maxillary bone, destroy- 
ing the gum and teeth, and denuding the alveoli. Recovery, if it take 
place at all under such circumstances, is with the loss of a portion of the 
bone, and with deformity. 

The duct of Steno is sometimes included in the gangrenous portion, 
but it commonly resists the destructive process, and remains per- 
vious. 

Age. — The age at which gangrene of the mouth occurs is usually 
between two and six years. In twenty-nine cases collated by Killiet and 
Barthez, twenty-one were between the ages of two and six years, and the 
remaining eight were from six to twelve years old. Of the cases which 
have fallen under my observation, most were between the ages of two and 
six years. It is seen that the period of greatest frequency of gangrene of 
the mouth is different from that at which the ordinary forms of stomatitis 
occur. 

Gangrene of the mouth may, however, occur under the age of one 
year. Billard reported three cases under the age of one month, but in 
two of these the disease does not appear to have been sufficiently marked 
to render it certain that they were genuine cases. 

Causes. — Gangrene of the mouth usually occurs in those whose sys- 
tems are reduced or cachectic. It is, therefore, more frequent among the 
poor than those in comfortable circumstances ; in the city than in the 
country. It is more frequently observed in asylums for children than in 
private practice. Most of the cases which I have seen have been in these 
institutions. If the constitution be naturally good, it can only occur in 
those long deprived of pure air and wholesome nutriment, or those en- 
feebled by disease. 

Among the diseases which have been known to terminate in or be fol- 
lowed by gangrene of the mouth, are the pulmonary and intestinal inflam- 
mations, hooping cough, and the fevers, both eruptive and the non-erup- 
tive. Rilliet and Barthez have published a table of ninety-eight cases in 
which gangrene resulted from other diseases. In forty-one of these the 
antecedent disease was measles, in five scarlet fever, six hooping cough, 
nine intermittent fever, nine typhoid fever, seven mercurial salivation, 
and five enteritis. It is seen that the essential fevers were the most fre- 
quent cause of the gangrene. Of forty-six cases collected by MM. Bou- 
ley and Caillault, the antecedent disease was measles in all but five. In 
this city, also, a larger number result from measles than from any other 
disease. 

One reason why so many cases of gangrene occur as a sequel of measles 



SYMPTOMS 



645 



is probably because this disease is accompanied by stomatitis. Simple or 
ulcerous stomatitis often precedes gangrene. 

Diseases sometimes terminate in gangrene of the mouth chiefly in con- 
sequence of injudicious treatment, which has lowered the vitality of the 
system. Rilliet and Barthez mention the case of a child four years old, 
in whom gangrene commenced at the twenty-ninth day of primitive pneu- 
monia. This child had been reduced by the application of twelve 
leeches, three scarifications, a large blister, and by the use of absolute diet. 

The misuse of mercury was once a much more frequent cause of 
gangrene than at present, at least in this country, since this agent was 
formerly much more employed than now. In fact most of the affec- 
tions of infancy and childhood in which mercurials were formerly em- 
ployed are now treated without it. 

Symptoms. — Gangrene of the mouth so often occurs in connection with 
other diseases, that its symptoms are in a large proportion of cases 
blended with those which arise from a distinct pathological state. 

Fig. 25. 




There is usually prostration more and more pronounced as the gangrene 
extends. The features are ordinarily pallid, but occasionally their nor- 
mal color is preserved for a time ; the expression of the face is melan- 
choly, but composed. Sometimes the child is fretful, if disturbed ; at 
other times it will quietly consent to an examination. The suffering is 
not proportionate to the gravity of the disease. There is less pain often 
than in some of the forms of stomatitis which are unattended with danger. 



64() G A N (i R E 2s E OF 'J' HE MO U T H . 

As the disease advances, the body and limbs gradually waste, the eyes 
are hollow, or, if the gangrene be near the orbit, the eyelids become 
(edematous, the lips are infiltrated, and both the lips and nostrils are 
often incrusted. If the cheek be perforated, alimentation is rendered 
more difficult, and the appearance of the child is melancholy in the extreme. 

The tongue is usually moist ; it is occasionally swollen. The saliva 
Hows from the mouth, either pure or mixed with offensive sanguinolent 
matter. Unless the disease be slight, there is the peculiar gangrenous 
odor. The appetite is sometimes poor, at other times it is preserved 
through the whole sickness. There is no vomiting or looseness of the 
bowels, unless from a complication. The thirst is usually great, and 
the pulse is accelerated and feeble, except in mild cases. 

The skin in the commencement of gangrene is hot. When the vital 
force is much reduced, and especially as the disease approaches a fatal 
termination, the face and limbs become cool, and the surface generally 
presents a waxen or ashy appearance. No derangement occurs of the 
respiratory system. Those cases which are attended by a cough or accel- 
erated respiration are really cases of bronchitis or pneumonitis, coexisting 
with, the gangrene. 

Diagnosis. — Gangrene of the mouth is easily diagnosticated. In those 
cases in which ulceration precedes the gangrene, it might be mistaken in 
its first stages for that form of ulcerous stomatitis in w T hich the ulcers 
assume an unhealthy appearance. The following are the distinguishing- 
features of the two affections : Around the ulcer where gangrene is 
about to coiumence the tissues are greatly thickened and indurated, or 
(edematous, while ulcerous stomatitis begins with a submucous deposit of 
fibrin, and is attended by little thickening of the surrounding parts, and 
little or no induration or oedema. In ulcerous stomatitis the skin over 
the seat of the disease presents its normal appearances, whereas in gan- 
grene it presents a distended and shining appearance. The destructive 
process in ulcerous stomatitis is also more limited than in gangrene. 
Deep ulcerations do not occur, or are rare. Ulcerous stomatitis is more 
readily healed, and it leaves no eschar, contraction, or deformity. 

The differential diagnosis of gangrene of the mouth from those cases of 
follicular stomatitis in which the ulcers occupying the seat of the follicles 
assume a gangrenous appearance, must be made by a consideration of the 
same facts or particulars wmich serve to distinguish it from ulcerous 
stomatitis. 

Malignant pustule, of rare occurrence in the child, resembles J Jiis dis- 
ease in some of its features. But the pustule always begins on the skin, 
while gangrene is a disease of the mucous surface primarily. In gan- 
grene, therefore, the chief destruction is of the mucous membrane and of 
the submucous tissue, while in malignant pustule the chief destruction is 
of the skin and the subcutaneous tissue. 



PROGNOSIS — TREATMENT. CA7 

Prognosis. — This depends not only on the extent of the gangrene, but 
the nature of the disease, if there be one, which gave rise to it, and the 
degree of cachexia. If it occur in connection with or as a sequel of one 
of the least debilitating diseases, and there be considerable vigor of system, 
it may often be arrested when it has destroyed only the mucous and sub- 
cutaneous tissues, so that no deformity results. The friends may con- 
gratulate themselves if the case terminate so favorably. In the graver 
cases, when the gangrene extends till it destroys the periosteum of the 
maxillary bone on the affected side, and perhaps perforates the cheek, if 
the child recover it is with the permanent loss of teeth, tedious separa- 
tion of the necrosed bone, and a cicatrix, which is apt to interfere with 
the free use of the jaw. Death is, however, the more common termina- 
tion of severe cases. Occasionally the gangrene destroys the continuity 
of a bloodvessel, causing abundant haemorrhage, and accelerating the fatal 
result. In most cases, however, there is little or no haemorrhage, in con- 
sequence of coagulation in the vessels. 

Another serious complication sometimes arises, namely, gangrene of 
other parts, as of the external genital organs. The English editor of 
Bouchut's treatise on diseases of children relates the following interesting 
case, from the Transactions of the Edin. JJedico-Chir. Society : 

An infant eight months old became affected with gangrene of the face, 
head, and hands. " The right ear and the entire hairy scalp were of an in- 
tensely black color, and on both cheeks patches existed about the size of 
a half-crown piece. The right thumb and the backs of both hands were 
similarly affected. The child was noted to have been restless and fever- 
ish on May 22d, and on the 23d a slightly darkened ring w r as found to 
have formed round the thumb, about the middle of the first phalanx ; in 
a few hours the whole thumb was gangrenous, and the dorsum of the 
hand became involved. On the ear the gangrene commenced with the 
appearance of a fleabite, and subsequently extended rapidly to the scalp, 
assuming a remarkable regular form, and giving to the child the appear- 
ance of wearing a black skull-cap. The pulse was observed to be very 
feeble. . . . Death took place in twelve hours from the first appear- 
ance of gangrene on the thumb, the child being sensible and continuing 
to suck well, up to a few minutes before death." 

Rilliet and Barthez state that pneumonitis is apt to arise in the course 
of gangrene of the mouth. Such a complication evidently diminishes 
materially the chance of recovery. 

Whether the result be favorable or unfavorable, it is evident, from the 
nature of the disease, that the duration is very different in different cases. 
The physician's attendance may be required for a week or two or for sev- 
eral weeks. 

Treatment. — As gangrene of the mouth is eminently a disease of de- 
bility, all anti-hygienic influences should be removed, and the most nour- 



648 GANGRENE OF THE MOUTH. 

ishing diet, together with tonics, be recommended. The ferruginous 
preparations or the bitter vegetables are required. 

As soon as the physician is called, he should endeavor to arrest the 
gangrene, accelerate the detachment of the slough, and produce a healthy 
and granulating state of the surrounding tissues. This is best effected by 
applying a highly stimulating or even escharotic agent to the inflamed 
surface underneath and around the gangrene. For this purpose a great 
variety of substances have been used by different physicians, such as 
acetic, sulphuric, nitric, and hydrochloric acids, nitrate of silver, the acid 
nitrate of mercury, chloride of antimony, and even the actual cau- 
tery. 

M. Taupin recommends, after removing a considerable part of the gan- 
grenous substances with scissors or some instrument, the application of 
strong muriatic acid, and, when the slough is detached, of dry chloride of 
lime. 

Rilliet and Barthez advised the use twice daily of muriatic acid or the 
acid nitrate of mercury, applied by a brush upon and around the slough, 
followed immediately by the application of dry chloride of lime, when 
the mouth is to be thoroughly washed with water from a syringe. They 
direct in the interval frequent ablution with water. After the slough has 
separated, the escharotic is to be discontinued, and the chloride of lime 
used alone. If gangrene extend to the skin, a crucial incision is to be 
made and the escharotic applied, after which powdered cinchona is intro- 
duced and retained by a plaster. This treatment is to be continued till 
the gangrene is arrested and the decayed portion removed. Barrier, 
Valleix, and most French writers, recommend essentially the same treat- 
ment, namely, the application of undiluted escharotic agents. 

A safer, less painful, and in many cases successful treatment, is that 
employed by many British and American physicians, namely, the use v of 
escharotic agents diluted, or, if applied in their full strength, such as are 
least active and penetrating. Some employ from the first topical treat- 
ment which is astringent and stimulating rather than escharotic, and they 
report satisfactory results. 

Dr. G-erhard believes " the best local applications are the nitrate of sil- 
ver, if the slough be small in extent ; if much larger, the best escharotic 
is the muriated tincture of iron, applied in the undiluted state. After the 
progress of the disease is arrested, the ulcer will improve rapidly under an 
astringent stimulant, such as the tincture of myrrh, or the aromatic wine 
of the French Pharmacopoeia." 

The local treatment recommended by Evanson and Maunsell differs from 
that advised by any of the writers from whom I have quoted. A knowl- 
edge of this treatment from which I have myself seen good results will 
be best imparted by quoting from the authors (Diseases of Children, 2d 
Amer. edit., page 188) : " The lotion which we have found by far the- 



TREATMENT. 64& 

most successful is a solution of sulphate of copper as employed by Coates 
in the Children's Asylum. His formula is as follows : 

"R. Cupri sulph., 3ij ; 

Pulv. cinchonas, §ss ; 
Aquae, 1 iv. M. 

" This is to be applied twice a day very carefully to the full extent of 
the ulcerations and excoriations. The addition of the cinchona is only 
useful by retaining the sulphate of copper longer in contact with the 
edges of the gums. A solution of the sulphate of zinc, 3 j to an ounce of 
water, by itself or combined with tincture of myrrh, Dr. Coates found to- 
be also useful in some cases." 

A moment's reflection will show us that the above treatment is pref- 
erable, provided that it is equally effectual in arresting the gangrene, to 
the treatment by the strong acids which are in common use, and the 
efficiency of which cannot be questioned. 

The purpose in applying the acid is to establish a healthier state of the 
tissues. It cauterizes and destroys whatever soft tissue it comes in con- 
tact with, besides it produces a strong corrosive action on the teeth and 
bone. Therefore in gangrene affecting the jaw, there is great danger 
that it will destroy the periosteum, and consequently increase the necrosis. 

Dr. West, who advocates the use of the acid (Diseases of Children, 
4th Amer. edit.), says: "In one of the cases that I saw recover, the 
arrest of the disease appeared to be entirely owing to this agent, 
though the alveolar processes of the left side of the lower jaw, from the 
first molar tooth backward, died and exfoliated, apparently from having 
been destroyed by the acid." No such result follows the use of the 
solution of sulphate of copper. 

In one of those severe cases in which the disease resulted from scarlet 
fever, and m which there was so much debility that an unfavorable prog- 
nosis was made, I succeeded in arresting the disease by the use of Dr. 
Coates's prescription. The child recovered with the loss of two teeth and 
the corresponding portion of the maxillary bone. From the good effects 
which I have observed from iodoform, as an application for gangrenous 
vulvitis following measles, it has occurred to me that it may also be use- 
ful in ^ano-rene of the mouth. 

If after employing the milder treatment for two or three days, the 
gangrene continue to spread, the strong muriatic acid should be cau- 
tiously applied by a camel-hair pencil or small swab, in such a way that 
it comes in contact only with the diseased surface. Its use should be 
immediately followed by an alkaline wash, as lime-water made turbid by 
lime. If the gangrene be of small extent, and do not involve the perios- 
teum, I would not hesitate to use the acid at my first visit, since it acts 
promptly in arresting gangrene, and with little pain. In May and June, 1881. 



650 DENTITION. 

an epidemic of measles occurred in the New York Foundling Asylum dur- 
ing the attendance of Drs. O'Dwyer and Lee. The number of children 
affected with it was 165, and since many of them were cachectic, we were 
not surprised that gangrene appeared as a complication or sequel in seven 
cases. In a girl of 3|- years, it appeared upon the upper jaw at the base 
of the teeth ; in two girls of four years it appeared upon the inside of the 
cheek and upon the vulva, and not upon the gums ; in a boy of three 
years it attacked the lower jaw, destroying four teeth with their sockets, 
and the upper jaw, destroying five teeth, with the corresponding portion 
of the maxillary bone, so that all the incisors and one canine were 
lost, as well as the cartilaginous portion of the nasal septum. Gangrene 
also occurred in the groin in this case. Another boy of 3|- years lost 
two incisors from gangrene of the jaw. The treatment by muriatic 
acid was employed, and according to the house physician, Dr. Kortright, 
there was no farther extension of the gangrene after the first application 
in any of the cases. All lived except the first, who had broncho-pneu- 
monia. The remaining two patients, aged respectively four years, died 
of diphtheria and pneumonia before treatment could be tested. One 
of them had commencing gangrene of the lower jaw, the other of the 
soft palate. 

The gases arising from the gangrenous mass are not only highly offen- 
sive to others, but they are doubtless injurious to the patient, who is 
constantly inhaling them. To remove the fetor, chlorine or carbolic acid, 
properly diluted, should be occasionally used between the applications of 
the sulphate of copper. Labarraque's solution, one part to eight or ten 
parts of water, is an eligible form for its use. When the gangrene is 
removed, and the granulations present a healthy appearance, all danger is 
usually past and convalescence is fully established. Then no energetic 
topical treatment is required. A mild stimulating lotion, like the tinc- 
ture of myrrh, as recommended by Dr. Gerhard, suffices, with the aid of 
tonics and nutritious diet. 



CHAPTER IY. 

DENTITION. 

The opinion formerly entertained in the profession, and now prevalent 
in the community, that many infantile maladies arise directly or indirectly 
from dentition, is erroneous. Still there are physicians of experience 
who believe that teething is a common cause of certain maladies, espe- 
cially of functional derangements, even of organs remote from the mouth. 
On the other hand, equally good observers, and the number is increasing, 



PATHOLOGICAL RESULTS OF DENTITION. 651 

almost wholly ignore the pathological results of dentition. They say 
that, as it is strictly a physiological process, it should, like other such pro- 
cesses, be excluded from the domain of pathology. 

A moment's reflection will show how important it is to understand the 
exact relation of dentition to infantile diseases. Every physician is called 
now and then to cases of serious disease, inflammatory and others, which 
have been allowed to run on without treatment, in the belief that the 
symptoms were the result of dentition. I have known acute meningitis, 
pneumonitis, and entero-colitis, even with medical attendance, to be over- 
looked, and the symptoms attributed to teething during the very time 
when appropriate treatment was most urgently demanded. Many lives 
are annually lost from neglected entero-colitis, the friends believing the 
diarrhoea to be symptomatic of dentition, a relief to it, and therefore not 
to be treated. Such mistakes are traceable to the erroneous doctrine, 
once inculcated in the schools, and still held by many of the laity, that 
dentition is directly or indirectly a common cause of infantile diseases and 
derangements. 

I shall endeavor to point out what is really ascertained in regard to the 
pathological relations of dentition. 

The first dentition commences at the age of about six months and termi- 
nates at the age of two and a half years. The corresponding teeth of the 
two sides pierce the gum at about the same time. The two inferior cen- 
tral incisors first appear at about the age of six or seven months, followed, 
in the order in which they are mentioned, by the upper central incisors, 
upper lateral incisors, lower lateral incisors, the four anterior molars, the 
four canines, and, lastly, the four posterior molars. 

The incisors usually appear in rapid succession, so that all are in sight 
by the age of one year. From the age of one year to sixteen months the 
anterior molars appear, from the age of sixteen to twenty-four months, 
the canines, and from twenty-four to thirty months the posterior molars. 
This order is not always preserved. Sometimes the upper central incisors 
appear before the lower, and sometimes the lower lateral before the upper 
lateral. In rare cases there have been teeth at birth. I have seen but 
one or two infants with such premature dentition. Retarded dentition is 
much more common. Those who have rickets, or are feeble either con- 
stitutionally or by disease, often have no teeth till considerably after the 
usual period. In such the first incisors may not appear till the age of 
twelve months, or even later. 

Pathological Results of Dentition. — The evolution of the teeth is 
commonly attended by more or less turgescence around the dental bulbs. 
This is greater with some of the teeth than with others. Thus, the supe- 
rior incisors cause more swelling than do their congeners of the inferior 
jaw. The turgescence, although attended by more or less congestion, is 
physiological within certain limits, and not a disease. 



652 DENTITION. 

Bat sometimes there is an unusual amount of swelling around the dental 
follicles ; the afflux of blood to them is greatly augmented ; they are the 
seat of such a degree of tenderness and pain that the infant is fretful. It 
carries the finger often to the mouth, indicating the seat of its suffering. 
The surface over the follicles presents greater redness than in ordinary 
dentition, and the salivary secretion is considerably increased. There is 
now actual gingivitis. 

Occasionally the inflammation affects a greater extent of the buccal sur- 
face than that lying directly over the follicles, so that most writers speak 
of stomatitis as one of the results of dentition. In a few cases I have 
known such a degree of inflammation over the advancing tooth, that a 
small abscess formed, producing much pain and restlessness, till it was- 
opened by the lancet. 

The pathological results of dentition which I have mentioned, though 
they may interfere more or less with the nursing or feeding, are not dan- 
gerous. They are easily detected. They result directly from the "rapid 
growth and augmented sensibility of the dental follicles. 

There are other supposed accidents of dentition occurring in distant 
parts of the system in consequence of the relation and interdependence of 
organs which exist through the system of nerves. 

Some children, previously to the eruption of the teeth, are affected 
with diarrhoea, occasionally accompanied by irritability of stomach. Cer- 
tain writers have supposed that gastro-intestinal catarrh is present in these 
cases ; others that there is simply a hypersecretion, an increased activity 
of the intestinal follicular apparatus, that it is, in other words, one of the 
forms of non-inflammatory diarrhoea. Barrier believes that the diarrhoea 
of dentition depends usually on what he calls a " subinflammatory tumes- 
cence limited to the gastro-intestinal follicular apparatus." He believes 
that, in occasional cases, it is due to defective or altered innervation. - It 
would then be analogous or similar to that form of diarrhoea which occurs 
in the adult from the emotions. Bouchut calls the diarrhoea of dentition 
nervous diarrhoea. It is certain, however, that in most cases of diarrhoea 
which are attributed to dentition there are other causes, such as unsuitable 
food, or residence in an insalubrious locality. It is certain, as regards 
city infants, that the chief causes of diarrhoea during the period of denti- 
tion are strictly anti-hygienic, dentition being quite subordinate a3 a 
cause, and probably ordinarily not operating at all as such. But when, as 
sometimes happens, at each period of dental evolution, the infant is 
affected with diarrhoea, the influence of teething is apparent. Such cases 
enable us to see that teething may really sustain a causative relation to 
certain diseases not located in the buccal cavity. 

Among the most common pathological results of difficult dentition, are 
certain affections referable to the cerebro-spinal system. Eclampsia is- 
one of the admitted results. Barrier attributes convulsions in the teeth- 



PATHOLOGICAL RESULTS OF DENTITION. 653 

ing infant to excitement of the nervous system arising from the pain 
which is felt in the gums, and to a determination of blood to the dental 
apparatus, in which afflux the whole vascular system of the head partici- 
pates. 

In most cases of convulsions occurring during the period of dental evo- 
lution, a careful examination discloses other causes in addition to the state 
of the gums. Difficult dentition must then be considered, not so fre- 
quently a direct as a co-operating or predisposing cause, producing a sensi- 
tive state of the nervous system, or possibly an afflux of blood to the 
head, of which Barrier speaks, and which, by an additional stimulus, per- 
haps trivial in itself, ends in convulsions. In exceptional instances 
eclampsia occurs mainly from dentition, or, if there are other causes, 
they are quite subordinate. This may happen when several teeth pene- 
trate the gum at or about the same time. Infants who are burned or 
scalded are very liable to clonic convulsions. This is, in fact, the chief 
danger as regards life from such accidents. So, the swollen and tender 
gum, if several teeth are about emerging, may affect the cerebro-spinal 
system like the burn or scald, and produce the same nervous phenomena. 
Thus, in a case already alluded to in the chapter on convulsions, five in- 
cisors pierced the gum within about two weeks, and in this period there 
were two attacks of eclampsia with an interval of a few days. The at- 
tacks were not severe, and the most careful examination could discover no 
other cause than the simultaneous development of so many dental folli- 
cles. Previously, and since, the infant has been well. 

Dentition, sometimes, though rarely, occasions also tonic convulsions. 
The following case occurred in the practice of Dr. A. S. Church, of this 
city, the history of which he has communicated, as follows : 

u H., seven months old, was first visited April 3, 1863. The patient 
had been fretful for several days, but about daylight on the morning of 
my first visit it commenced crying, and had not ceased for a moment at 
the time of my visit, 9 a.m. The bowels were somewhat constipated 
and tympanitic ; abdominal muscles very tense. The pain was supposed 
to be in the abdomen, and a brisk cathartic, to be followed by an ano- 
dyne, was ordered. Some relief followed, but, on the ensuing and for 
several consecutive mornings, the pain returned, each day lasting longer, 
until the" child only ceased crying while under the influence of a full ano- 
dyne. The gum over the upper incisors was considerably swollen, hot, 
and dry, but the parents would not consent to have it scarified. For the 
first week there was no fever, no vomiting, and not the least indication 
that the nervous system was suffering. About the 10th the thumbs were 
noticed to be flexed during the attack of pain, and about the 15th the 
flexors of the toes were contracted and the hands were turned backward 
and outward, but only w T hile the child was awake. About the 20th there 
was constant contraction of the flexors of both extremities, with opistho- 
tonos, and constant rolling of the head, loss of appetite, progressive 
emaciation, coated tongue, and highly inflamed gums. Consent was, 



654 DENTITION. 

finally, obtained to relieve the inflamed gum, and free incisions were 
made, and the following night the child slept comfortably for three hours 
without opiates. In three days the gums were freely cut again, and the 
teeth soon made their appearance. All symptoms of disease had now 
ceased, the child became playful, and on 30th the patient was dis- 
charged.' ' 

The opinion has been prevalent in the profession, that painful and diffi- 
cult dentition is one of the chief causes of infantile paralysis, but it is now 
commonly admitted that it is only a subordinate or remote cause, if in- 
deed it is proper to consider it as a cause at all. (See Art. Paralysis.) 

Some writers express the opinion that acute meningitis occasionally 
results from teething. The facts, however, that are relied upon to prove 
this are uncertain. The occurrence of meningitis during dentition is 
probably in most instances a coincidence. 

Teething less frequently disturbs the respiratory system than either the 
digestive or cerebro-spinal. A cough occurs in some infants at each 
period of dental evolution. It is attended by little expectoration, but ap- 
pears to be associated with, in at least certain cases, an inflammatory 
turgescence of the bronchial mucous membrane. 

Acceleration of pulse is often observed at the time of greatest swelling 
and tenderness of the gum. It subsides with the protrusion of the tooth. 
The febrile movement of dentition is irregular, sometimes presenting a 
remittent form, like remittent fever or the fever premonitory of menin- 
gitis. Eczema and certain other cutaneous diseases are common during 
dentition, but their dependence on it as a cause has not been demon- 
strated. 

Diagnosis. — The accidents of dentition which are located in the mouth 
are easily diagnosticated, except the odontalgia which writers describe, 
and which is not necessarily attended by any perceptible anatomical alter- 
ation of the gums. Those accidents which pertain to remote and con- 
cealed organs are usually detected with ease, though it is often difficult to 
determine with certainty their relation to dentition. 

When similar symptoms arise at each epoch of teething, and subside 
with the subsidence of the gingival turgescence, teething must be regarded 
as the cause. Or, if the disease be such as is known to be produced occa- 
sionally by difficult teething, and if, after a careful examination, we can 
discover no other cause, while the gums are swollen, especially over two 
or more advancing teeth, it is proper to refer the malady to dentition. 

It is evident that we must often be in doubt whether the disease which 
we are treating be due at all to the state of the gums, or, if so, whether 
directly or indirectly, or to what extent ; but, as a rule, if any other cause 
be apparent, w T e may properly regard the influence of dentition as quite 
subordinate. 

Treatment. — It is obvious that remedial measures in cases of difficult 



TREATMENT. 655 

dentition must be twofold, namely, those directed to the state of the 
gums, and those designed to relieve the derangements or diseases to 
which dentition has given rise. If there be diarrhoea, this should be con- 
trolled by proper remedies, so as to reduce the number of evacuations to 
two or three daily. It is well to state to the friends of the child, who 
believe that diarrhoea is salutary during the period of teething, that this 
number is quite sufficient, and that more frequent evacuations will endan- 
ger the safety of the child. 

The nervous affections, as convulsions, require such soothing and deriv- 
ative measures as are recommended in our remarks on diseases of the 
nervous system. The bromide of potassium I have found especially use- 
ful and safe in cases of fretfulness and nervous excitement due to denti- 
tion. The rational employment of therapeutic measures requires strict 
attention to be given to the causes of disease. Therefore, the physician 
called to treat an ailment, believed to be due to dentition, should not fail 
to examine the state of the gums, and adopt such measures as will mitigate 
the intensity of the cause — in other words, diminish the tenderness if not 
the swelling of the gum. Demulcent and soothing lotions are sometimes 
useful. The infant should be allowed to hold in the mouth an india-rub- 
ber or ivory ring, which, by pressure on the gum, gives considerable relief. 

Mothers will often attempt to " rub through a tooth," as they term it, 
by means of a ring or thimble. This should be discouraged. So great 
friction cannot fail to have an injurious effect, by increasing the swelling 
and inflammation, unless the tooth have already reached the mucous mem- 
brane. 

We come now to a subject which has engaged the attention of many 
physicians of ample experience, and in reference to which there is still 
a difference of opinion among the highest authorities in medicine. I 
refer to scarification of the gums. 

The gum-lancet is now much less frequently employed than formerly. 
It is used more by the ignorant practitioner, who is deficient in the ability 
to diagnosticate obscure diseases, than by one of intelligence, who can 
discern more clearly the true pathological state. Its use is more frequent 
in some countries, as England, under the teaching of great names, than in 
others, as France, where the highest authorities, as Rilliet and Barthez, 
discountenance it. 

It is well to bear in mind, as aiding in the elucidation of this subject, 
the remark made by Trousseau, that the tooth is not released by lancing 
the gum over the advancing crown. The gum is not rendered tense by 
pressure of the tooth, as many seem to think, for, if so, the incision 
would not remain linear, and the edges of the wound would not unite, as 
they ordinarily do, by first intention within a day or two. This speedy 
healing of the incision, unless the tooth be on the point of protruding, is 
an important fact, for it shows that the effect of the scarification can only 



656 DENTITION. 

last one or two days. The early repair of the dental follicle is probably 
conservative, so far as the development of the tooth is concerned. It may 
help us to understand how active, how powerful, the process of absorp- 
tion is, if we reflect that the roots of the deciduous teeth are more or less 
absorbed by the advancing second set, without much pain or suffering 
from the pressure. If the calcareous particles of the teeth are so readily 
absorbed, what is the foundation for the belief that the fleshy substance 
of the gum is absorbed with such difficulty ? Too much importance has 
evidently been attached to the supposed tension and resistance of the gum 
in the process of dentition. 

Follicles in the period of development are especially liable to inflamma- 
tion. We see this in the follicular stomatitis and enteritis, so common 
when the buccal and intestinal follicles are in the state of most rapid 
growth. Does not this law in reference to the follicles hold true of those 
by which the teeth are formed, so that the period of their enlargement 
and greatest activity, which corresponds with the growth and protrusion 
of the teeth, is also the period when they are most liable to congestion 
and inflammation ? This fact affords a better explanation of the fre- 
quency of the so-called laborious or difficult dentition than that it is due 
to the resistance which dental evolution encounters from the gums. 

If there be no symptoms except such as occur directly from the swell- 
ing and congestion of the gum, the lancet should seldom be used. The 
pathological state of the gum which would, without doubt, require its use, 
is an abscess over the tooth. As to symptoms which are general or 
referable to other organs, as fever and diarrhoea, the lancet should not be 
used if the symptoms can be controlled by other safe measures. All co- 
operating causes should first be removed, when in a large proportion of 
cases the patient will experience such relief that scarification can be 
deferred. 

If the state of the infant be one of immediate danger, as in eclampsia, 
and it be not quickly relieved by the ordinary remedies, scarification 
may not only be proper but required to insure safety. For in such cases 
all measures, provided that they are safe and simple, which can possibly 
give relief, should be employed without delay. But I can recall to mind 
only two accidents of dentition which would be likely to be benefited by 
scarification, namely, suppurative inflammation in the dental follicle and 
convulsions. But since the bromide of potassium and hydrate of chloral 
have come into use as nervous sedatives, and as efficient remedies for 
clonic convulsions, scarification of the gums is much less frequently re- 
quired, for even severe eclampsia commonly yields to these medicines, if 
the condition of the bowels be attended to. 



SECOND DENTITION. 657 

Second Dentition. 

The fact is well established, though often overlooked in practice, that 
second dentition occasionally deranges the functions of organs, and gives 
rise to pathological symptoms. Rilliet and Barthez mention particularly 
neuralgic pains, rebellious cough, and diarrhoea, as effects which they 
have observed. Rilliet relates the case of a girl, eleven years old, who 
had a very obstinate and protracted cough, the paroxysms lasting often 
half an hour to one hour. This cough immediately and permanently dis- 
appeared when the molars pierced the gums. 

Dr. James Jackson, in his Letters to a Young Physician, says : " I 
have seen persons between twenty and thirty years of age much affected 
by a wisdom tooth not yet protruded, and distinctly relieved by cutting 
the gum. But I think the most common period of suffering from the 
second dentition is from the tenth to the thirteenth year. The most 
characteristic affections are wasting of flesh and nervous diseases. The 
boy loses his comeliness, and his complexion is less clear, while emaciation 
takes place in every part, though mostly, perhaps, in the face. The 
nervous symptoms are various, but the most common are a change in the 
temper and a loss of spirits. With these there is some loss of strength. 
The patient is unwilling to engage in play, and soon becomes tired when 
he does do it. Among the distinct symptoms which are not uncommon, 
I may mention pain in the head and in the eyes. The headache is not 
commonly severe, but it is such as inclines the patient to keep still. The 
eyes are not only painful, but are often affected with the morbid sensi- 
bility to which these organs are subject. I have known boys truly anx- 
ious to pursue their studies obliged to give them up on this account ; and 
these, not having the disposition to play, will of choice pass the day with 
their mothers, and increase their troubles by the want of air and exercise. 
Nervous affections of a more severe character are sometimes manifested. ' ' 

Whether the symptoms which have been attributed to second dentition 
have always been due to this cause, is questionable. Practically, how- 
ever, it matters little whether we recognize dentition as the cause, or 
assign something else. Hygienic and medicinal measures to improve the 
general health will usually suffice to relieve the patient. Elsewhere I have 
related the case of a boy, of nervous temperament, about seven years old, 
who recovered immediately from a cough which had lasted for several 
weeks, by taking a mixture of iron and nitric acid. Many do well with- 
out medicine, simply by hygienic measures. Dr. Jackson says : " The 
remedies which I have found most useful are as follows : First, a relief 
from study or from regular tasks, yet using books so far as they afford 
agreeable occupation or amusement. Second, exercise in the open air, 
preferring the mode most agreeable to the patient, and in more grave 
cases the removal from town to country." 
42 



658 CATARRHAL PHARYNGITIS. 



CHAPTER Y. 

CATARRHAL PHARYNGITIS, PERIPHARYNGEAL ABSCESS, (ESOPHA- 

GITIS. 

Children of all ages are liable to inflammation of the pharynx. In its 
mildest form it often, doubtless, escapes detection in the young infant. 
In older patients it is revealed by pain in swallowing solid food, and more 
or less tumefaction below the ears, apparent to the sight. It is said to 
be less frequent in infancy than in childhood. In the adult, and in chil- 
dren over the age of four or five years, inflammation of the pharyngeal 
surface is often confined to the portion of membrane which covers or im- 
mediately surrounds the tonsils. It occurs in connection with inflamma- 
tion of these glands. But in infancy and early childhood this limitation 
is comparatively rare. Catarrhal inflammation of the fauces at this age is 
ordinarily general, the tonsils participating in the morbid state. 

Pharyngitis is primary or secondary. The secondary form occurs in 
measles, scarlet fever, bronchitis, croup, pneumonitis, and occasionally in 
other affections. As these diseases are common, physicians are oftener 
called to treat patients who have the secondary form than the primary. 
Rilliet and Barthez met eighty -three secondary to sixteen primary cases. 

Anatomical Characters. — The pathological anatomy of pharyngitis is 
ascertained by depressing the tongue and inspecting the fauces. The 
faucial surface is seen to be redder than in health, with more or less 
swelling, according to the intensity of the inflammation. In the primary 
inflammation the color is commonly bright red, almost like that of arterial 
blood. If, on the other hand, the inflammation occur in connection 
with a constitutional malady, the hue is apt to be darker. In grave cases 
of scarlet fever or measles it is sometimes even livid, indicating a vitiated 
state of the blood, a condition of real danger. The tonsils are tumefied 
so as to project, though not to the extent which we often observe in the 
adult. They are then less firm than in the normal state. The follicles of 
the throat are enlarged and active, pouring out a muco-purulent secretion. 
This is sometimes seen in a layer over the tonsil or the posterior portion 
of the fauces. In a case of primary pharyngitis examined after death by 
Rilliet and Barthez, the tonsils were softened, infiltrated with pus, and 
slightly enlarged. A layer of bloody mucus lay on the pharyngeal sur- 
face, which was dark-red, thickened, and glandular. The submaxillary 
glands were also swollen and somewhat softened. 

If the inflammation be intense, the deep-seated portions of the tonsils 



CAUSES — SYMPTOMS — PROGNOSIS. 659 

become involved, and even sometimes the adjacent connective tissue. In 
such cases, by applying the fingers in the hollows below the ears, the 
tonsils can be felt. 

Causes. — The usual cause of primary pharyngitis is exposure to cold. 
It also occasionally occurs from the use of drinks too hot or containing 
some irritating substance. I have met it in the most intense form caused 
by swallowing boiling water, and, in one case, from acetic acid taken 
through mistake. When it occurs in the eruptive fevers, it is usually 
part of a more extensive phlegmasia, in which the buccal and perhaps 
laryngeal and nasal surfaces participate. 

Symptoms. — Fever, with thirst and loss of appetite, is common, and is 
usually proportionate, in intensity, to the extent and severity of the in- 
flammation. At first there is dryness of the faucial surface, and this is 
succeeded by a more or less abundant viscid secretion. Swallowing is 
painful, except in mild cases. The muscles of the anterior half arches, 
which, by their contraction, close the opening from the pharyngeal to the 
buccal cavity, and those of the posterior arches, which close the opening 
to the nasal cavity, both which sets lie a little under the mucous mem- 
brane, are often so infiltrated with serum that their contractile power is 
diminished, and if the same happen with the constrictor muscles, which 
carry downward the food, swallowing becomes difficult, and in the at- 
tempt, more or less of the ingesta is apt to return into the mouth, or 
enter the nostril. During health the air passes through the nostrils in 
the pronunciation of two letters only, namely, N and M, but in severe 
pharyngitis, in consequence of the swelling, and the impairment of the 
action of the muscles concerned in speech, the air passes through the nos- 
trils with the utterance of many words, producing the nasal tone of voice. 
Sometimes the inflammation traverses the Eustachian tube to the middle 
ear, causing earache, which may be relieved by the escape of pus down 
the tube, or by perforation of the drum into the external ear. 

The breath is foul, but not fetid ; the respiration normal, or but 
slightly accelerated ; there is commonly no cough, but it is sometimes 
present, due to the extension of the inflammation to the upper part of the 
larynx, or to the collection of mucus around the aperture of the glottis. 
In most cases of pharyngitis a light fur covers the tongue, and stomatitis 
of a mild grade is present, as shown bv the redness of the buccal surface, 
and an increased mucous secretion. 

Chronic pharyngitis, which is so common in adults, and which is pro- 
duced in some by gastric derangements, and in others by excessive smok- 
ing, or the prolonged use of intoxicating drinks, and in others, still, by 
the syphilitic or mercurial cachexia, is comparatively rare in children. 

Prognosis. — In mild cases of pharyngitis convalescence commences 
within a week. If the inflammation be dependent on a constitutional mal- 
ady it may continue considerably longer, especially if the glands of the 



660 CATARRHAL PHARYNGITIS. 

neck, and the connective tissue, be much involved. The prognosis in 
secondary pharyngitis is less favorable than in that of the primary form. 
In fatal cases there is usually a vitiated state of the blood, either from the 
coexisting constitutional disease, or from previous cachexia. 

Pharyngitis may, however, become dangerous from complications to 
which it gives rise. The proximity of the inflammation to the brain, or 
its effect upon the cerebro-spinal axis through the medium of the nerves, 
sometimes gives rise to clonic convulsions. In a recent case of primary 
pharyngitis in my practice, repeated and violent convulsions occurred in 
an infant, about one year old, from this cause. They commenced at the 
inception of the inflammation, and constituted the only real danger. 
Pharyngitis may interfere materially with nutrition in consequence of the 
dysphagia, but in most cases of primary pharyngitis this symptom does 
not continue sufficiently long to endanger the life of the patient. In 
grave constitutional affections, as scarlet fever, the difficulty of swallow- 
ing, and the consequent innutrition, augment the danger. As regards, 
therefore, the prognosis in catarrhal pharyngitis, whether primary or sec- 
ondary, it may be stated as a rule, that it is not, per se, a fatal disease, 
but is only so from complications, or from aggravating the primary mal- 
ady with which it is associated. 

Diagnosis. — This is not difficult provided that attention be directed to 
the throat ; but the physician often fails to discover it at his first visit, 
from neglecting to examine this part. In many cases the local symptoms 
are not well-marked, and in the absence of these the febrile reaction may 
at first be referred to some other cause than the true one. Inspection not 
only reveals the presence of inflammation, but enables us to determine 
whether it be simple pharyngitis, or diphtheritic, or ulcerative. In some 
instances, simple pharyngitis resembles the diphtheritic, from the presence 
of confervoid growths upon the inflamed surface, usually the leptothrix 
buccalis. The differential diagnosis is based on the easy removal and soft 
pultaceous character of the confervae, and the appearance under the 
microscope. 

Treatment. — Mild cases of simple pharyngitis require little treatment. 
With moderate counter-irritation over the throat, and the use of laxative 
medicines, the inflammation soon subsides. The oleum camphoratum 
may be occasionally rubbed over the throat, and retained upon it by flan- 
nel. The effect is increased by the application, once or twice daily, of 
mustard or tincture of iodine, or by adding to the liniment one fourth or 
one third of its quantity of turpentine. 

Some children seem to be most relieved by a muslin compress fre- 
quently wrung out of cool water, or a light india-rubber bag containing 
ice. Frequently rubbing the neck with warm oil or camphorated oil, and 
binding upon it a rind of salt bacon, are popular modes of treatment, 
and no doubt are productive of benefit. 



PERI-PHARYNGEAL ABSCESS. 661 

In the severe forms of this inflammation, occurring independently of 
any other disease, more acute measures are sometimes required. 

If there be stupor or restlessness, with unusual heat of head, and start- 
ing or twitching of the limbs which threaten convulsions, two to five 
grains of the bromide of potassium given every two or three hours pro- 
duce an excellent calmative effect. 

Diaphoretics and sometimes cardiac sedatives are also indicated, such 
as liquor ammonise acetatis, spiritus setheris nitrosi, ipecacuanha, and 
aconite. Medicines of this kind may be variously combined according to 
the age and condition of the patient, and the severity of the disease. 

As the symptoms abate, the intervals between the doses may be in- 
creased. 

In cases attended by much tenderness and dysphagia great relief is often 
obtained by hot poultices frequently applied over the neck. 

Topical treatment of the pharynx is recommended by most authors. 
Rilliet and Barthez use for this purpose nitrate of silver or powdered 
alum. The former has been most employed by physicians. It may be 
applied in the proportion of ten grains to the ounce two or three times 
daily. I prefer the following mixture, used with the hand atomizer 
every two or four hours : 

3. Acid, carbolic, gtt. xxxij ; 
Potas. cklorat., 3 iij ; 
Glycerinae, 5 iij > 
Aquae, 5 vj. Misce. 

This can of course be used as a gargle by those old enough, or more 
continuously by the steam atomizer. 

The treatment of secondary pharyngitis will be described in connection 
with the treatment of the diseases which it complicates. Suffice it here 
to say that this form of inflammation must not be treated by those 
depressing remedies which are useful in certain cases of idiopathic 
pharyngitis. 

Peri-Pharyngeal Abscess. 

Every practitioner should bear in mind the fact that an abscess occa- 
sionally forms between the pharynx and vertebral column (retro-pharyn- 
geal), or upon the side of the pharynx in the submucous connective tis- 
sue. This constitutes a disease which is apt to be fatal, but which can 
ordinarily be promptly relieved by the surgeon. 

Yet, if we look over the records of peri-pharyngeal abscess, we shall 
see that in a large proportion of fatal cases, the disease was supposed to 
be something else, and so treated until its nature was revealed by post- 
mortem examination. The most complete monograph on this malady 



662 PERI-PHARYNGEAL ABSCESS. 

with which I am acquainted was published by Dr. Allin, of this city, in 
the JV. T. Jour, of Med. for November, 1851, under the title of retro- 
pharyngeal abscess. To this paper I am largely indebted for facts. 

Age — Cause. — This abscess may occur at any age, but it is most com- 
mon in infancy and childhood. It is more frequent in the first two years 
of life than at any other period. Of the cases collated by Dr. Allin, in 
which the age v is stated, twenty were under ten years, and twenty-one over 
this age. The abscess occurs in some patients from caries of the verte- 
bral column, and, in others, from inflammation developed in the connect- 
ive tissue or small lymphatic glands lying immediately outside the pha- 
rynx, or from a catarrhal pharyngitis. Whichever the cause, there is 
usually a scrofulous or reduced state of system. 

Writers describe two kinds of peri-pharyngeal abscess, the primary and 
secondary. This distinction is based on the fact, whether or not the in- 
flammation which leads to the abscess be dependent on an antecedent 
pathological state. 

In the primary form the cause is usually atmospheric, or it is some irri- 
tating substance which has been swallowed, and which, lodging in the 
pharynx, produces phelgmonous pharyngitis. 

The cause is mentioned in twenty cases of the primary form, collated 
by Dr. Allin, as follows : exposure to cold, ten cases ; lodgment of bone 
in pharynx, eight cases ; blow with a fencing-foil, one case. In the last 
case the button of a fencing-foil passed through the right nostril into the 
pharynx. 

The secondary form occasionally occurs after measles and scarlet fever. 
The inflammation of the pharynx, common in those diseases, extends to 
the subjacent connective tissue, and, aided by the dyscrasia of the patient, 
becomes suppurative. Such cases have been observed by Rilliet and Bar- 
thez. The most common cause of the secondary form is, however, caries, 
occurring in the cervical vertebrae. 

When thus occurring it is similar, both as regards cause and nature, to 
lumbar abscess. It would follow the same chronic course, and would 
properly be described in connection with it, were it not for its proximity 
to the air-passages, which renders the symptoms so urgent and dangerous. 
In a few recorded cases the abscess was a sequel of erysipelas. In nine- 
teen cases of secondary abscess, in Dr. Allin' s collection, the cause is as- 
signed as follows : erysipelas of face, two ; inflammation following a fall 
upon the inferior maxilla, one ; after cerebritis, one ; syphilis, four ; 
caries of the cervical vertebrae, six ; scrofula, five. 

The plausible opinion is expressed by Mr. Fleming (Dublin Journ. of 
Med. Sci., vol. xviii.), that the suppuration begins, in a large proportion 
of cases, in the small lymphatic glands which lie in the connective tissue 
external to the pharynx. The late Prof. Geo. T. Elliot has recorded the 
case of an infant of seven months [Obstet. Clinic, N. Y., Appleton & Co., 



I 
ANATOMICAL CHARACTERS — SYMPTOMS. 663 

1868), in whom peri-pharyngeal abscess immediately followed, and was 
apparently due to parotiditis. 

In rare instances the abscess, or the local disease which leads to it, ap- 
pears to exist from birth. Thus, Dr. E. 0. Hocken relates, in the Prov. 
Med. and Surg. Journ., 1842, the history of an infant who died at the 
age of nine weeks. It had always, when taking the breast, thrown back 
its head as if nearly suffocated. The walls of the abscess were thick and 
firm, described by the writer as cartilaginous. Occasionally there is no 
apparent cause of the abscess, except the strumous or cachectic state. 

Anatomical Characters. — The seat of the abscess is not the same in 
all cases. The swelling can ordinarily be seen on examining the fauces, 
but occasionally it is so low as to be really peri- oesophageal, and, there- 
fore, invisible. The size of the abscess varies ; sometimes it is large, 
pressing inward the wall of the pharynx even against the velum palati and 
into the posterior nares, if the abscess have a high location, or, if lower, 
against the larynx, so as to embarrass respiration. Sometimes the abscess 
is so large, or has such lateral extension, that there is external swelling 
along the side of the neck. In a few cases on record the pus, instead of 
being discharged into the pharynx, made its way down the neck between 
the muscles and the connective tissue to the pleural cavity, which it 
entered, producing fatal pleuritis. 

The walls of the abscess have been found in a different state in different 
cases. Sometimes the sac, at the projecting point, is so thin that it seems 
as if there might have been a spontaneous cure, could life have been pre- 
served a few hours longer. In other cases the sac is so thick and firm 
that its rupture, for many days, would be impossible. 

Symptoms. — The precursory symptoms differ in different cases, accord- 
ing to the nature of the cause, whether it be phlegmonous pharyngitis or 
simply adenitis or vertebral caries. If the abscess proceed from caries, it 
is preceded by deep-seated pain, greatly increased by movements of the 
head, and probably by induration along the sides of the vertebras. 

The patient with this disease is restless, his mouth hot and dry ; tongue 
furred ; deglutition more or less difficult. Sometimes after suppuration 
has occurred there are alternations of rigors and fever. The symptoms 
indicate approximately the seat of the inflammation, but on examination 
we do not find that degree of redness of the mucous surface which we had 
been led to expect. The tissues which are chiefly involved in the inflam- 
mation, being submucous, are hidden from view. We observe redness of 
the pharynx, but it is disproportionate to the intensity of the symptoms. 
Sometimes there is a sensation of chilliness through the entire period of 
the abscess, though greater at one time than at another, and occasionally 
convulsions occur, especially in young infants. In ordinary cases embar- 
rassment of respiration begins early, and is the cause of the chief danger. 
It becomes more and more marked as the abscess increases. It is noticed 



664: PERI-PHARYNGEAL ABSCESS. 

both during inspiration and expiration. The dysphagia also increases, 
sometimes to such a degree that drinks are taken with difficulty, and solid 
food refused. The respiratory symptoms bear considerable resemblance 
to those in protracted laryngitis, for which this disease has been mis- 
taken. While the respiration becomes impeded or whistling, the voice 
is also feeble or indistinct, from the pressure of the tumor. 

But the symptoms described above are not all present in every case. 
They vary according to the size and location of the abscess, whether it be 
high or low, posterior or lateral. I have met the disease in a child old 
enough to express its subjective symptoms, in whom there was little or 
no dysphagia, and others report similar cases. When the tumor has at- 
tained such a size as to produce well-marked symptoms and jeopardize 
the life of the patient, it, or a part of it, can ordinarily be seen on de- 
pressing the tongue, but usually its location and condition can be better 
ascertained by exploration with the finger. The dyspnoea increases as 
the abscess enlarges, and, after a time, unless it burst spontaneously or be 
opened by the surgeon, imperfect oxygenation of the blood results. In 
some patients paroxysms of dyspnoea occur, so as to threaten immediate 
suffocation ; coughing or attempts to swallow induce these paroxysms, 
and the patient is forced to remain in an erect or semi-erect posture. 
The tongue is protruded, the head thrown back, the pulse is frequent 
and rapid, the limbs become livid and cool, and finally death results from 
dyspnoea. Occasionally, when death seems inevitable, the abscess breaks 
during the struggles of the child, and the patient is restored to health. In 
rare cases the result is different. The trachea and bronchial tubes are del- 
uged by the purulent discharge, and immediate suffocation occurs. The 
following was an example : In May, 1871, a boy two years and five months 
old was brought to the class at Bellevue, who had had the symptoms of 
an abscess for three months. The head was carried on one side, its rpta- 
tion caused pain, and a laryngeal rale accompanied respiration. The upper 
part of the tumor could be detected by the finger ; but, on account of its 
low location, it was impossible to open it with the bistoury. The tem- 
perature was 103°, pulse 156. The case was kept under observation, but 
in a few days the dyspnoea suddenly became so urgent that death was im- 
minent, when the attending physician of the class, Dr. Swezey, broke the 
abscess with his finger, and pus was ejected on the floor ; death, however, 
occurred almost immediately. 

A correct appreciation of the symptoms and the nature of peripharyn- 
geal abscess will be best obtained by relating a case. I select the follow- 
ing from the Trans, of the Lond. Pathol. Soc, Oct. 20, 1846 : 

A female infant died at the age of seven months, having had difficult 
breathing three weeks, and extreme dyspnoea during the last days of life. 
The dyspnoea was constant, and was aggravated by mental excitement, by 
movements of the body, and by exposure to cold. During the parox- 



SYMPTOMS. 665 

ysms a peculiar, croupy sound accompanied inspiration. There was no 
dysphagia through the entire sickness, and death occurred from apnoea. 

The sac of the abscess was of the size of a pigeon's egg, and was situ- 
ated between the upper cervical vertebrae and the back of the pharynx. 
The abscess was flattened in front, so as not to cause any decided promi- 
nence of the wall of the pharynx. From the sac a second small cyst ex- 
tended forward, forming a nipple-like swelling in the pharynx, which 
completely closed the orifice of the glottis. Its aperture of communica- 
tion with the body of the abscess admitted the point of the little finger, 
and the whole swelling was freely movable and perfectly translucent at its 
extremities and sides. The abscess might have been easily punctured, 
with probably the preservation of life. 

The duration of this malady is very different, according to the severity 
of the inflammation, the rapidity with which the abscess enlarges, and the 
direction which it points. A lateral or downward extension is not so 
immediately dangerous to life as the anterior. 

The time when the abscess begins to form cannot be precisely ascer- 
tained, and most writers, in determining its duration, compute from the 
first appearance of symptoms which are referable to the pharynx. Dr. J. 
Bryne relates, in the Amer. Journ. of Med. Sci., 1838, a fatal case in 
which the disease had apparently continued only about one week. The 
patient was an infant one year old, and its death was from apnoea. The 
abscess was large, extending from the base of the skull to the thorax, and 
pressing both on the larynx and trachea. M. Besserer (Archiv Gen. de 
Med., 1840) gives the history of an infant four months old, who died in 
the same way after thirteen days. An infant nine months old, whose case 
was published by Dr. W. C. Worthington, in the Prov. Med. and Surg. 
Journ., 1842, lived nine days. The abscess occurred from exposure to 
cold ; the patient was treated for croup, and died from suffocation. The 
anterior wall of the abscess was very thin. Since the first edition of this 
book was published, I have met four patients with this disease in whom 
the pus was evacuated when the dyspnoea had become urgent. In two 
the symptoms indicated a continuance of the disease from two to four 
weeks, and in the third case four months. The fourth case is interesting 
on account of the short duration of the severe symptoms. The following 
is the record of it : M. E., aged 7 months, female, nursing, inmate of the 
New York Foundling Asylum, was observed to have difficult breathing for 
the first time, on March 28, 1875. Since about March 8, some swelling 
had been noticed along the side of the neck, but it gave rise to no marked 
symptoms and she had not seemed ill, till the obstruction in the respiration 
commenced. At my visit on the evening of the 28th, the infant was 
pointed out to me as in a dying condition. She was lying in a state of 
stupor, pallid, and gasping for breath, with a temperature of 103°, and very 
feeble pulse, numbering about 200 per minute. On carrying the finger 



666 PERI-PHARYNGEAL ABSCESS. 

into the throat an abscess could be readily detected, situated in the walls 
of the pharynx on the left side posteriorly. This was easily opened by a 
curved bistoury, around which adhesive plaster was wound to within 
half an inch of the point. The breathing immediately began to improve. 
On the following day the infant was playing in the mother's lap, with a 
pulse of 140, but a normal temperature. With the use of cod-liver oil 
and the syrup of the iodide of iron, its health was soon fully restored. 

When the abscess grows slowly, and presses lightly on the air-passages, 
the case may continue for months. Such a one was observed by Profes- 
sor Willard Parker. (Allin.) This infant was one year old ; it suffered 
from pharyngeal symptoms nine months, was treated for tonsillitis, and 
death occurred as usual from apncea. The abscess was two inches long, 
and there was no disease of the vertebrae. The same surgeon saved the 
life of another patient four years old, in whom the disease was protracted, 
by puncturing the abscess ; and Professor Post, of this city, also treated 
successfully a case which had continued three months. (Allin.) 

Diagnosis. — The diagnosis of this disease is ordinarily easy, provided 
that the physician examine carefully and bear in mind the occasional 
occurrence of such an abscess. In a large proportion, however, of the 
recorded fatal cases, the true nature of the disease was not recognized 
during life. Especially is the diagnosis difficult when the cerebrospinal 
system is early implicated, and symptoms arise which divert attention 
from the throat to the brain. 

The maladies with which peri-pharyngeal abscess is most frequently 
confounded are laryngitis and simple but severe pharyngitis. From laryn- 
gitis, for which it has been most frequently mistaken, it may be distin- 
guished by the dysphagia and by the character of the initial symptoms. 
In laryngitis there is usually the peculiar cough from the first or very 
early, while in abscess there is an initial period of several days or even 
weeks before respiration is materially affected. This is the period of in- 
flammation which precedes suppuration. 

In abscess pressure of the larynx backward is badly tolerated, greatly 
increasing the dyspnoea, while in pharyngitis and croup this effect is not 
so marked. In abscess the horizontal position aggravates the dyspnoea, 
but not in pharyngitis and croup. The character of the voice will also 
aid in diagnosticating abscess from laryngitis, since in the former it is apt 
to be nasal, and in the latter hoarse or whispering. The decisive test is 
afforded by inspection and digital exploration. The tumor is seen, or, if 
situated too low to be seen, is felt, upon the walls of the pharynx. 

If the symptoms of abscess are masked by those arising from the cere- 
brospinal system, as by convulsions, the priority of the pharyngeal symp- 
toms will serve to aid in determining the true disease. 

In a case of suspected abscess the physician should not only carefully 
inspect the fauces, but should employ digital examination. The finger 



(ESOPHAG-ITIS. 667 

will often detect fluctuation when no evidence of an abscess or uncertain 
evidence is presented to the eye. 

Prognosis. — With proper treatment the result is usually favorable, but, 
if the disease be not recognized, many die. In Dr. Allin's cases, of those 
under the age of twelve years nine died, while ten recovered by the 
opening of the abscess by the lancet, trocar, or finger, and one by its 
spontaneous rupture. 

If the abscess be due to disease of the spinal column, death may occur 
immediately after t}ie sac is opened, the caries of the intervertebral carti- 
lages producing, according to Dr. Allin, dislocation of the vertebrae. 
Death may also occur, though rarely, from pleuritis, in consequence of 
the bursting of the abscess into the pleural cavity. Even in caries, if the 
sac be properly opened, and if need be reopened, and the head supported 
by suitable apparatus, recovery is possible, as in a case treated by Prof. 
Post. 

Treatment. — The proper treatment of peri-pharyngeal abscess is sim- 
ple, consisting in breaking or puncturing the sac by the finger, the lancet, 
bistoury, or pharyngotome. Each method has been successfully em- 
ployed. In the majority of cases the proper way to open the abscess is 
by the ordinary curved scalpel or bistoury, which should be covered by a 
strip of adhesive plaster to within a half inch of the point. If the ab- 
scess be post-pharyngeal, it should be opened in the median line. A sin- 
gle incision suffices to evacuate the pus. If the abscess point or be elas- 
tic, there is little danger of wounding any important vessel or producing 
dangerous haemorrhage if the operation be properly performed. It may 
be necessary to open the abscess more than once, as in a case reported by 
Dr. Post, and another which I saw with Dr. Livingston, of this city. In 
certain cases, when the knife cannot be readily employed, the abscess may 
be opened by pressure with the finger-nail or the edge of a teaspoon. 

Patients with this disease ordinarily require constitutional treatment, 
especially the use of tonics, ferruginous and vegetable. The citrate of 
iron and quinine, the citrate of iron and ammonium, and in strumous cases 
the syrup of the iodide of iron with cod-liver oil, are eligible prepara- 
tions. Nutritious diet and often alcoholic stimulants are required. 

CEsophagitis. 

Disease of the oesophagus in infancy and childhood is comparatively 
rare, inflammation being the most frequent affection of this portion of the 
digestive tube in these periods, and, indeed, the only one which claims 
attention. It is most common in infants under the age of three or four 
months, who are deprived of the breast-milk, and are given a diet which 
is with difficulty digested, and perhaps taken too hot or too cold. It is, 
therefore, most common in foundling hospitals. I have frequently ob- 



668 (ESOPHAGITIS. 

served it in the Infants' Hospital, and the Nursery and Child's Hospital, 
of this city, chiefly at the autopsies of bottle-fed infants, under the age of 
six months, whose symptoms had indicated disease or derangement of the 
digestive function. Many of them had diarrhoea, and died in a state of 
emaciation. Oesophagitis in these cases was associated with simple or 
gangrenous stomatitis, thrush, or with gastritis or entero-colitis. Some- 
times all these inflammations coexisted. In a few cases the confervoid 
growth of thrush had extended from the mouth to the oesophagus. It 
occurred in small hemispherical masses, scarcely as large as a pin's head. 
Swallowing corrosive or strongly irritating substances, as the acids or 
alkalies, is an occasional cause of oesophagitis, the irritant at the same 
time producing stomatitis and gastritis. 

Anatomical Characters. — The inflamed surface sometimes presents a 
uniformly injected appearance. Usually, however, there is greater inten- 
sity of inflammation in streaks or patches than over the surface generally. 
I have frequently observed at autopsies a greater degree of inflammation 
in the lower than upper half of the oesophagus, even when the infant had 
stomatitis at the time of death. 

Oesophagitis occurring from faulty regimen or anti-hygienic conditions 
is not accompanied by as much thickening of the walls of the tube as 
often occurs in some other portions of the digestive canal, as, for exam- 
ple, in the colon. Diphtheritic inflammation of the oesophagus is accom- 
panied by so great infiltration of the mucous membrane and underlying 
connective tissue that I have seen the oesophageal walls three or four 
times the normal thickness. 

Occasionally ulcerations of the oesophageal mucous membrane are ob- 
served in the lower part of the tube, and Billard describes the ulcerative 
form of oesophagitis. At the first autopsies at which I observed these 
ulcers, I supposed that they were pathological, and indicated a severe 
grade of inflammation ; but a more extended observation has convinced 
me that they are usually post-mortem, and are not at all dependent on in- 
flammations of the oesophagus. The solvent power of the gastric juice not 
only causes ulceration in the stomach, but entering the oesophagus may 
and not infrequently does produce a solvent action on the mucous tissue 
there. At the meeting of the London Pathological Society, March 4, 
1852, Dr. Graily Hewitt presented a specimen in which the gastric juice 
had not only eaten entirely through the coats of the oesophagus an inch 
above the stomach, but had even attacked the left lung. Over the age of 
six months inflammation of the oesophagus is rare. 

The symptoms of oesophagitis, in those young and emaciated infants in 
whom it ordinarily occurs, are not well-pronounced. Pain in deglutition, 
or tenderness on pressure over the oesophagus, if present, is ordinarily not 
appreciable. Nor have they seemed to me to vomit oftener than other 
infants of this class who suffered from indigestion and gastro -enteritis, 



INDIGESTION. 669 

without oesophagitis. It is, therefore, difficult to diagnosticate oesopha- 
gitis in them. It is, according to my observation, oftener present than 
absent in spoon-fed infants of three months or under who have persistent 
stomatitis and entero-colitis. 

Treatment. — In the oesophagitis of foundlings and ill-nourished in- 
fants, which arises, as has been stated, from faulty regimen, no treatment 
is required apart from that designed to relieve the stomatitis or entero- 
colitis with which it occurs. Attention must be directed mainly to the 
diet and hygienic management. The remedial measures are more fully 
detailed in our remarks on entero-colitis. OEsophagitis produced by swal- 
lowing corrosive or highly irritating substances requires the same treat- 
ment as in the adult, namely, poultices, demulcent drinks, etc. 



CHAPTEE YI. 

INDIGESTION, CONGESTION OF STOMACH, GASTRITIS, FOLLICULAR 
GASTRITIS, DIPHTHERITIC GASTRITIS, POST-MORTEM DIGESTION, 
SOFTENING. 

Indigestion is more common during infancy than in any other period 
of life. While the digestive organs in the adult easily assimilate a great 
variety of food, it is necessary for the well-being of the infant that its 
diet be simple and carefully prepared. Departure from this rule leads to 
indigestion and ulterior diseases. 

After the age of two years a mixed diet is readily assimilated, the 
digestive function less frequently disordered, and indigestion presents few 
peculiarities to distinguish it from that of the adult. 

Indigestion in some children is habitual ; in others the digestive pro- 
cess is ordinarily well performed, but, from some temporary derangement 
of system or error of diet, an acute attack of indigestion occurs. Hence, 
two forms of this ailment may be described ; first, acute, referring to 
temporary attacks ; secondly, chronic, referring to the habitual state. 

Causes. — The causes of indigestion are twofold : first, the condition of 
the digestive function independently of the aliment ; secondly, the un- 
wholesome or improper character of the ingesta. Anything which lowers 
the vital powers may be a predisposing cause of indigestion, by impairing 
the function of the organs which assimilate the food. Impure air and 
personal uncleanliness, protracted hot weather, and previous disease, are 
among the common predisposing causes. The strong country child can 
thrive upon a diet which, given to the more feeble child of the city, 
would produce deleterious results. During the summer months it often 
happens that an infant in the city cannot digest properly any food given 



670 INDIGESTION. 

to it except the mother's milk ; and from this results much of the infan- 
tile sickness and mortality which make this season of the year so much 
dreaded by parents. There is a natural difference in children, as regards 
liability to disordered digestion. Some do well upon a diet which given 
to others similarly situated occasions vomiting, gastralgia, and flatulence. 

In the majority of cases of indigestion, however, the fault does not ex- 
ist in the child. It is fed too often or irregularly, or upon a diet that is 
unwholesome or indigestible. It is well known that the milk of the 
mother or the wet-nurse is liable to chauges which render it for the time 
unsuitable for the infant. Her food may be of such a quality, or her 
mind so excited, or some function of her system so disordered, as to 
effect a temporary change in the constitution of the milk. The occur- 
rence of the catamenia, or of gestation, in mothers who are suckling, not 
infrequently produces this unfavorable result. 

Indigestion is most common in those infants who, deprived of the 
mother's milk, are intrusted to wet-nurses, or fed from the bottle. The 
milk of the wet-nurse, from not agreeing with the age of the infant, from 
irregularity in her mode of life, from the acescent nature of her food, or 
from other causes which are not appreciable, may disagree with the in- 
fant, and be imperfectly digested. 

The most common cause of indigestion in the infant is artificial feed- 
ing. This, in the cities, is productive of a great amount of gastric and 
intestinal derangement and disease. The younger the infant, the less fre- 
quently does it thrive if brought up by hand. 

Whatever care may be bestowed in the preparation of its food, whether 
cow's or goat's milk, or farinaceous substances be used, there is seldom 
that healthy nutrition which is observed in infants who receive the breast- 
milk. The " swill milk" in common use among the poor families of 
this city is totally unfit for the feeding of infants, and is apt to cause flat- 
ulence, acidity, and indigestion. Acute indigestion occurs in children of 
any age from food unsuitable in quality or quantity, which produces gas- 
tralgia and other symptoms to be detailed hereafter. Those who suffer 
habitually from mal-assimilation are especially liable to such acute attacks. 

In the period of childhood, chronic indigestion is much less frequent 
than in infancy, but children are, perhaps, more subject than infants to 
the acute form. This is induced by ingesta taken in too large quantity, 
or of a kind which is with difficulty digested. Cherries, currants, raisins, 
and the parenchyma of oranges and lemons, dried fruits and confectionery, 
which are so often heedlessly given to children, are common causes of 
acute attacks of indigestion. These substances, being but partially 
digested or not at all, and sometimes accumulating for days in the stom- 
ach or intestines, may lead to a very serious and dangerous condition. 

Symptoms. — The nursing infant, if the milk continually disagree with 
it, is fretful. It has a discontented aspect. It seldom smiles, and is not 



SYMPTOMS. 671 

amused by playthings, or is only amused for a short time. Its features 
are pallid, and bear the appearance of faulty nutrition. Its body and 
limbs are more or less wasted, or are soft and flabby. Vomiting is fre- 
quently present, and sometimes a large mass or masses of casein are 
ejected, which have evidently lain a considerable time in the stomach. 
The bowels may be constipated or loose, and the evacuations are un- 
healthy. This state of the infant continuing prevents the necessary rest 
of the mother, and may affect unfavorably her health, so as to reduce the 
quantity of her milk, or render it still more unwholesome. 

In addition to the habitual indigestion, these infants sometimes have 
acute attacks, similar to the acute dyspepsia of adults, and which have 
been described by writers as gastralgia or enteralgia. Their countenance 
indicates suffering ; they utter sharp cries, their thighs are often drawn 
over the abdomen, notwithstanding attempts made to amuse them. Flatu- 
lence is common. By vomiting or an evacuation from the bowels, the 
offending substance is removed, and the pain subsides. 

Indigestion in the spoon-fed infant is similar to that in the infant who 
nurses, except that it is ordinarily accompanied by symptoms of greater 
gravity and persistence, and there is in such infant more liability to the 
acute attacks. 

In those who have advanced beyond the age of infancy, chronic indi- 
gestion is less frequent than in infants, but as the diet of such children is 
prepared with less care, and is less restricted, they are very liable to at- 
tacks of temporary indigestion. These come on suddenly, and sometimes 
are so severe as to endanger life. The child, previously well, is suddenly 
seized with languor ; the pulse becomes accelerated, the face flushed, and 
surface hot. Drowsiness compels him to seek the bed, where he lies with 
his eyes shut. He sometimes has headache, and a sensation of oppression 
in the epigastrium. The nervous system is not infrequently affected, as 
shown by tenderness of a neuralgic character of the body and limbs, sud- 
den twitching of the limbs premonitory of convulsions, and occasionally 
severe and repeated convulsions. These alarming and really dangerous 
symptoms speedily subside on the removal of the cause. One of the 
most severe attacks of eclampsia which I have seen occurred in a boy 
eight or ten years old, induced by swallowing the parenchymatous por- 
tions of oranges which he had been in the habit of eating, and which 
had accumulated in the stomach and intestines. The expulsion of the 
offending substance gave immediate relief. 

Sometimes, but not often, the symptoms of acute indigestion closely 
resemble those of pneumonitis. For example, an infant, whom I once 
treated, was seized at night with fever, hurried respiration, and the expi- 
ratory moan, which writers consider almost pathognomonic of pneumonitis 
or pleuritis. These symptoms subsided when the bowels were freely opened, 
and currants, which had been eaten the previous day, were expelled. 



672 INDIGESTION. 

As the child advances in years and its general health improves, the 
digestive function is less frequently disturbed. After the age of three or 
four years indigestion is much less frequent than in infancy and early 
childhood. 

Indigestion leads to some of the most common and serious affections of 
early life. In the infant, if it continue a considerable time, inflammation 
of the buccal, oesophageal, or gastric mucous membrane, or of some part 
of the intestinal tract, ordinarily occurs. In the young infant thrush 
soon makes its appearance, and, whatever the age, the cachexia which re- 
sults from continued indigestion increases the liability to organic mala- 
dies. Eclampsia is, as we have seen, a serious, and at the same time a 
not infrequent, result of temporary or acute indigestion. 

Prognosis. — In simple indigestion this is good. It is doubtful or un- 
favorable when ulterior diseases occur, and in proportion to their gravity. 

Treatment. — The first indication in treatment is obviously the removal 
of the cause. In acute indigestion, when there is reason to believe that 
there is some offending substance in the stomach or intestines, if the 
symptoms occur soon after the substance is taken, an emetic may be ad- 
ministered, and ipecacuanha, in syrup or powder, is safe and usually effi- 
cient. If several hours have elapsed a purgative should be given, as cas- 
tor oil, either alone or in combination with syrup of rhubarb. 

If the symptoms be urgent, especially if convulsions be threatened, we 
should not wait for the slow action of a purgative, but should resort to 
enemata to open the bowels. Sometimes the pain in acute indigestion is 
such as to require the use of opiates. In the infant there is often an ex- 
cess of acid in the stomach and intestines, which is best treated by alka- 
line remedies, as lime-water in combination with the opiate. The follow- 
ing mixture will be found useful in such cases : 

9. Tinct. opii deodorat., or liq. opii composit. (Squibb's), gtt. xij ; 
Magnes. calcinat., gr. xij — xxiv ; 
Sacch. alb., 3j ; 
Aq. anisi, 1 iss. Misce. 

Dose, the bottle being first shaken, one teaspoonful every two hours to a child 
a year old, until relief. If there be much pain, it is well to add a little chloroform 
or Hoffman's anodyne to the mixture. 

Or the following mixture : 

5. Tinct. opii deodorat.. or liq. opii composit., gtt. xij ; 
Bismuth, subcarbonat., 3 iss ; 
Syr. simplic, 1 ss. Misce. 
Aq. cinnamomi, §j. 
Shake bottle thoroughly and give one teaspoonful. 

If in the acute indigestion of infants diarrhoea occur, the campho- 



TREATMENT. 673 

rated tincture of opium, in combination with chalk mixture, may be given, 
fifteen drops of the one to a teaspoonful of the other, or the above mix- 
ture. Infants, whose diet consists largely of cow's or goat's milk, digest 
with most difficulty the casein, which is apt to pass the bowels in an im- 
perfectly digested state, or to collect in a large and firm mass in the stom- 
ach, causing gastralgia and rendering the child fretful till it is vomited. 
I have elsewhere recommended, as important to prevent these attacks of 
acute dyspepsia, the use of the upper third of the milk, which contains 
less than the average casein, and the addition of an alkali to the milk, 
which retards the coagulation till it begins to be acted upon by the gastric 
juice, and tends to prevent the formation of large and firm caseous 
coagula in the stomach. The addition of a little farinaceous food, as 
barley water, to the nursing-bottle will sometimes produce the same effect 
by mechanically separating the particles of milk. 

In chronic indigestion the means of relief are different. They are two- 
fold : first, as regards change of diet ; secondly, measures to improve the 
digestive function. Spoon-fed infants, suffering from habitual indiges- 
tion, require the utmost care as regards the character of their food, its 
preparation, and the times of feeding. Often it is best, if practicable, to 
procure a wet-nurse, and sometimes removal to a more salubrious locality 
is followed at once by improvement in the digestive function. If the in- 
fant be already wet-nursed, the milk should be examined microscopically 
and otherwise, and inquiry should be instituted in reference to the health 
and diet of the wet-nurse. Sometimes a change of wet-nurse is advisable. 
For facts and considerations bearing on this point the reader is referred to 
the chapters relating to regimen. 

Children with chronic indigestion are occasionally much benefited by 
the moderate and judicious use of alcoholic stimulants. They should be 
given sparingly with their food, and should be discontinued as soon as 
the digestive function is fully restored. M. Donne and some other 
French writers recommend the habitual use of wine for infants even in a 
state of health, but there are reasons, moral as well as physical, why 
alcoholic stimulants should only be used as medicines, and not in a state 
of health. 

If the case be one of simple or uncomplicated indigestion, pepsin or lacto- 
peptin of the shops and tonics may be employed. In many instances, how- 
ever, especially in infancy, gastro-intestinal inflammation has supervened, 
and in such cases those tonics should be employed which exert a favor- 
able, or, at least, not an unfavorable effect on the hyperaemic and irritable 
surface over which they pass. 

When indigestion is simple, or accompanied by no serious complica- 
tion, wine of iron, citrate of quinine and iron, and the elixir of calisaya 
bark, may be mentioned among the safe and efficient agents to improve 
the digestive function. 
43 



674: CONGESTION OF THE STOMACH. 

The ferruginous preparations are most efficacious in cases which are 
attended by signs of anaemia. 

Among the useful vegetable stomachics and tonics may be mentioned 
the compound tincture of cinchona, compound tincture of gentian, infu- 
sion of columbo, fluid extract of columbo, and fluid extract of cinchona. 

If chronic indigestion be complicated with gastro-intestinal inflamma- 
tion, subacute or chronic, for this is the form which is usually present,, 
there are still certain tonics which may be advantageously administered. 
Columbo and the compound tincture of cinchona are often useful in these 
cases, and of the chalybeates wine of iron or the citrate of iron and 
ammonium or the liquor ferri nitratis may be safely administered. In most 
cases, however, change in the diet properly made will be found more use- 
ful than tonic and corrective medicines. 

I have only alluded to the use of pepsin as a remedial agent in indiges- 
tion. The theory of its employment in atonic states of the stomach is 
good, but physicians in this country have, in most instances, I think, not 
observed that benefit from its use which they have been led to expect, and 
which seems to have followed its employment in the practice of some of 
the European physicians. Perhaps the result would have been better had 
fresher and better preparations of pepsin been prescribed. Imported 
pepsin has been most used in this country, but the recent American prep- 
arations are, in my opinion, preferable on account of the care bestowed 
in their preparation, and their freshness. I have prescribed pepsin in 
doses of two or three grains, several times daily, to foundlings from one 
to three months old, and in proportionate doses to older infants, but I am 
not able to speak confidently of its effects, as I have commonly given it 
with bismuth. 

The American pepsin, prepared under the intelligent supervision of 
experienced chemists, can be obtained in the shops in the form of a pow- 
der or liquid. That now prepared by Dr. Hawley, of Brooklyn, is 
among the best. 

Infants affected with diarrhoea from indigestion often improve under 
the use of powders consisting of equal parts of subnitrate of bismuth and 
pepsin. An infant of three months can take three grains of each every 
three hours. 

Dyspepsia often rapidly disappears by hygienic measures without the 
use of medicines, as by removal from the city to the country, outdoor 
exercise, or, if the patient be an infant, by being carried into the open air 
daily. In infants, also, marked improvement is often observed on the 
approach of the cool and bracing weather of autumn and winter. 

Congestion of the Stomach. 

Passive congestion of the stomach is described among the diseases of 
this organ by Billard ; but it is a pathological state of little importance in 



GASTRITIS. 075 

itself. It occurs in new-born infants, asphyxiated at birth and w ith diffi- 
culty resuscitated. In these cases there is generally intense capillary con- 
gestion throughout the system. The mucous membrane of the stomach is 
injected, but not more than that of the mouth or intestines. If circula- 
tion and respiration be fully established, this injection of the capillaries 
subsides. No treatment is required, except measures to promote the cir- 
culatory and respiratory functions. In cyanosis and atelectasis there is 
often general congestion of the capillaries of the systemic circulatory sys- 
tem, on account of the obstruction to the flow of blood through the heart 
in the one disease and through the lungs in the other. There is in these 
cases passive congestion of the stomach, but not more than of the other 
organs. 

Gastritis. 

Inflammation of the stomach, except when produced by the direct con- 
tact of some irritant, is rare in infancy and childhood, independently of 
disease in some other portion of the intestinal tract. Cases have, how- 
ever, been reported in which it was not known that any irritating ingest a 
had been taken, and in which a careful examination revealed a healthy or 
nearly healthy state of other portions of the digestive tube. The sub- 
jects were, for the most part, young infants. The following is an exam- 
ple related by Billard : 

An infant, four days old, remarkable for the color of his face and firm- 
ness of flesh, refused the breast, and vomited yellow, acid matter. On 
the following day the vomiting had increased, the legs were (edematous, 
face pallid and pinched, respiration difficult, skin cold, pulse slow and 
irregular, and pressure on the epigastric region produced cries indicative 
of pain. 

Third day : general sinking ; face thin and expressive of great pain ; 
stools natural. 

Fourth and fifth days : condition the same. Death occurred on the 
sixth day, and the autopsy was made on the day following. 

With the exception of slight pneumonitis, no disease was discovered in 
any part of the system besides the stomach. The mucous membrane of 
this organ was intensely vascular near the cardiac orifice and along the 
lesser curvature. This part was also tumefied, and could be easily raised 
with the finger-nail. The remainder of the gastric surface was hyperse- 
mic, but to a less extent. 

This case is interesting as showing what may happen, though rarely. A 
nursing infant is seized with gastritis without apparently having taken any 
irritating ingesta, and without other disease of the digestive apparatus. 
It is probable, however, that, in cases like the above, the cause, if ascer- 
tained, would be found in the ingesta ; perhaps drinks too hot, perhaps 
elements of colostrum, or pathological elements in the milk, which might 



676 GASTRITIS. 

produce gastritis in young infants in whom the mucous membrane is deli- 
cate and sensitive. 

Gastritis is not uncommon in infancy in connection with inflammation 
of the intestines. The latter inflammation is sometimes apparently sub- 
ordinate to the former, and, if such patients die, the fatal result is due 
mainly to the gastric disease. The reverse is, however, the rule. The 
gastritis is ordinarily subordinate to the intestinal catarrh. 

Cause. — Gastritis, as I have observed it in infants, has been in most 
cases due in great part to the continued use of improper food, of food not 
suitable to the age of the child, and which was, therefore, with difficulty 
digested. Milk, acid, or otherwise unwholesome, farinaceous sub- 
stances, stale or of an inferior quality, and not properly prepared, drinks 
too hot or too cold, may be specified among the causes. Therefore, this 
disease is most common in bottle-fed infants, and is comparatively rare in 
those who receive abundant and wholesome breast-milk. Anti-hygienic 
agencies, apart from the diet, no doubt exert some influence in the pro- 
duction of gastritis, as they do of stomatitis. Uncleanliness, and resi- 
dence in damp and dark apartments, or in an atmosphere loaded with 
noxious gases, produce a condition of system which strongly predisposes to 
these inflammations, if, indeed, they may not be enumerated among the 
direct causes. 

Rilliet and Barthez have called attention to the fact that certain medici- 
nal substances given to children occasionally cause gastritis. They have 
observed this effect from the use of tartar emetic, Kermes mineral, and 
croton oil. Gastritis occurring in this way may or may not be associated 
with inflammation in contiguous portions of the digestive tube. Else- 
where I have related a case in which gastro-enteritis occurred in a child 
nine years old, after having taken a considerable quantity of kerosene oil 
for spasmodic croup. 

Inflammation of the stomach is thought by some to accompany measles 
and scarlet fever during the eruptive period, but this opinion is probably 
incorrect. If it occur, it corresponds with the stomatitis and dermatitis 
of those diseases, and disappears as they subside. It is mild, and accom- 
panied by few symptoms. I have, as stated in the remarks on scarlet 
fever, examined in certain instances the stomachs of those who have died 
during the eruptive period of these diseases, and found them free from 
any appreciable inflammatory lesion. 

Age. — From the records of about seventy cases of inflammatory disease 
of the digestive mucous membrane which I have preserved, it appears 
that gastritis is rare over the age of six months. On the other hand, it is 
not uncommon in infants under the age of three months who are deprived 
of the breast-milk. I have met it chiefly in foundlings fed with the bot- 
tle, and having at the same time entero-colitis and often also stomatitis 
and oesophagitis. In these cases there is sometimes continuous or almost 



case. 677 

continuous injection and thickening of the mucous membrane, from the 
lips to near the pyloric orifice of the stomach, and even beyond this ori- 
fice in the intestines. The following is an example of gastritis as it fre- 
quently occurs in foundling institutions : 

Case. — R. "W., female, two weeks old, was admitted into the New 
York Infant Asylum, August 24, 1865, anaemic and somewhat emaciated. 
It was in part wet-nursed, and in part bottle-fed. The emaciation in- 
creased, and nearly the entire buccal cavity became covered with the con- 
fervoid growth of thrush. On September 4th, diarrhoea commenced. 
Borax was used for the mouth, and alkalies and astringents to check the 
diarrhoea, but without material improvement. 

The following was the record for September 7th : " Cries almost con- 
stantly, with feeble or whining voice ; still has thrush ; nurses and does 
not vomit ; stools five or six daily, and green ; pulse 136, feeble.'' 
Death occurred September 8th. 

Autopsy September 9th. — Mouth and fauces not examined ; mucous 
membrane of oesophagus vascular in its whole extent, with slight thicken- 
ing, but without ulceration ; mucous membrane of stomach injected like 
that of the oesophagus, and somewhat thickened, except in its pyloric ex- 
tremity, where the appearance was natural, or nearly so ; the color in the 
central part of the inflamed gastric membrane was deep red ; no thrush 
was noticed, except on the buccal surface during life ; along the great 
curvature of the stomach were white flakes, resembling those of thrush, 
but which were found by the microscope to consist mainly of oil-globules 
and epithelial cells, without the cryptogamic formation ; mucous mem- 
brane of small intestines healthy in their whole extent, except slightly in- 
creased vascularity in a few places in the ileum ; mucous membrane of 
colon much injected throughout, except near the ileo-ca?cal valve, where 
the vascularity was slight ; in the transverse and descending colon the 
redness was pretty uniform ; and the membrane was thickened, but not 
ulcerated ; solitary glands and Peyer's patches somewhat elevated. 

The observations of Valleix show how frequently gastritis is associated 
with severe attacks of thrush. In twenty-three of his cases of the latter 
disease, in which the condition of the stomach was noted after death, 
this organ presented inflammatory lesions in seventeen, and in three 
others appearances which may or may not have been due to inflammation. 

Symptoms. — A difficulty exists in isolating and defining the symptoms 
of gastritis, from the fact that it commonly coexists with other inflamma- 
tions of the digestive tube. Though we may never be able to diagnosti- 
cate this catarrh as certainly as we can croup or pneumonitis, still, there 
are symptoms which arise directly from the gastritis, and with care we 
may be able to distinguish them from those symptoms which are due to 
other pathological states. 

If gastritis be acute, pain is present. In the above case from Billard, as 
well as in a case observed by myself and related under the head of gela- 
tinous softening, there were frequent cries, and the countenance indicated 
much suffering, until the stage of collapse. If there be less intensity of 



678 GASTRITIS. 

inflammation, and the disease be more protracted, as is ordinarily the case, 
the pain is not so severe, and it may be so slight as not to attract atten- 
tion. Sometimes there is tenderness, so that pressure upon the epigastric 
region is badly tolerated. Vomiting is regarded as one of the most con- 
stant symptoms. The infant after nursing seems in distress till the milk 
is returned, but it nurses with avidity in consequence of the thirst, if it 
be not too exhausted or feeble. The dejections may be quite regular 
throughout the disease, as in the case from Billard. There is ordinarily, 
however, diarrhoea from the presence of entero-colitis. The pulse is some- 
times accelerated, and sometimes nearly natural. The emaciation in gas- 
tritis is rapid, since not only the milk is in great measure vomited, but 
the digestive function, so far as the stomach is concerned, is seriously im- 
paired. The features become wrinkled and senile, the eyes hollow, the 
limbs attenuated, and the cranial bones uneven. Death occurs from ex- 
haustion. 

Anatomical Characters. — Simple gastritis may affect the entire 
mucous surface of the stomach, or be limited to a certain part. The part 
which is most likely to escape is that toward the pyloric orifice. This 
portion of the organ is sometimes found in nearly or quite the normal 
state, while the cardiac half or two thirds is inflamed. The vascularity 
of the diseased surface is not uniform. In one place there is simple 
arborescence ; in another intense continuous redness, and between these 
two extremes are different grades of vascularity. The mucous membrane 
is somewhat thickened, softened, and the secretion of mucus increased. 
Extravasation of blood is not infrequent under the mucous membrane, 
usually in points, and mucus may be mixed with more or less blood. 
Small shreds or portions of coagulated milk are often found with the 
mucus attached to the gastric surface. I have observed, though rarely, 
small superficial ulcers at the point where the inflammation had been most 
intense. 

Diagnosis. — In protracted cases, when entero-colitis is present, it is 
difficult to make a positive diagnosis. Our opinion must then be little 
more than a plausible conjecture. In the acute attacks we can diagnosti- 
cate the gastritis with more certainty. If a young infant affected with 
sprue be seized with pain, and it vomit often ; if emaciation be rapid, 
and there be no diarrhoea, or diarrhoea not sufficient to account for the 
prostration ; if the buccal mucous membrane, dotted with the points of 
thrush, present a dry appearance and the deep-red color of severe stoma- 
titis, there can be little doubt of the presence of gastritis. The diagnosis 
is rendered more certain by signs of tenderness when pressure is made 
upon the epigastric region. 

Prognosis. — Like other inflammations, gastritis is probably sometimes 
so mild that it does not materially increase the suffering or danger of the 
child. This mild form of the disease under favorable circumstances soon 



DIPHTHERITIC GASTRITIS. 679 

subsides. In other cases, by the continuance or increase of the cause, the 
inflammatory process becomes more severe and extensive, resulting even 
in disintegration of the mucous membrane. Those cases are especially 
severe and likely to end fatally, which are protracted and accompanied by 
severe thrush, with a desiccated appearance of the buccal surface, or with 
entero-colitis. Pain, vomiting, and rapid emaciation in such children in- 
dicate the speedy approach of death. Improvement in the stomatitis or 
entero-colitis is a favorable indication, but these inflammations may im- 
prove without corresponding improvement in the gastritis. 

Treatment. — All food or drinks, except those of a bland and unirritat- 
ing nature, should be forbidden. If practicable, the young infant should 
take no nutriment except the mother's milk or that of a wet-nurse. As 
there is an excess of acid in inflammation of the mucous coat of the 
digestive tube, lime-water may be advantageously given in combination 
with the breast-milk. Opium is required to relieve the pain and quiet 
the action of the stomach. The camphorated tincture of opium, in doses 
of four or five drops to a child a month old, or the syrup of poppy, tinc- 
ture of opium, or liquor opii compositus, in proportionate doses, may be 
administered. If there be thirst, a little gum-water should be given fre- 
quently. If there be much emaciation and the vital powers are failing, it 
will be necessary to resort to the use of stimulants. Stimulating enemata 
are preferable to stimulants given by the mouth. Much benefit may be 
anticipated from local measures. Irritation should be produced upon the 
epigastrium by mustard or other means, followed by fomentations. It is 
rarely, perhaps never, proper to use leeches, if the patient be a young in- 
fant. Death occurs from exhaustion, and it is, therefore, important that 
the vital powers should not be reduced. If the child be weaned, the diet 
at first should be restricted to arrowroot, rice-water, barley-water, or sim- 
ilar bland substances. In advanced stages of gastritis, animal broths and 
jellies may be required. 

Follicular Gastritis — Diphtheritic Gastritis. 

The pathological character of follicular gastritis is similar to that of fol- 
licular stomatitis. It is an inflammation affecting the gastric follicles and 
ending in their ulceration. It is not a frequent disease ; it occurs in 
young infants. Billard observed fifteen cases. The symptoms in these 
patients were similar to those in simple gastritis of a severe form. The 
emaciation and prostration were rapid, and death occurred early. We 
can only diagnosticate the gastritis without determining its follicular char- 
acter. How many recover it is impossible to ascertain, but the disease is 
apt to be fatal on account of the intensity of the inflammation, not only 
of the follicles but of the intervening mucous membrane. The treatment 
is that of o-astritis. 



680 SOFTENING. 

Diphtheritic gastritis is infrequent. It occasionally occurs during 
epidemics of diphtheria. Allusion is elsewhere made to a case treated in 
the Nursery and Child's Hospital of this city, in December, 1859. The 
patient, eighteen months old, previously had had protracted entero-colitis, 
and died exhausted after a brief attack of diphtheria. There were 
lesions referable to the entero-colitis, and the body was much emaeiated. 
The diphtheritic exudation was found covering the fauces, epiglottis, 
glottis, to the rima glottidis, the entire oesophagus, and almost the entire 
stomach. The mucous surface underneath was injected ; that of the 
oesophagus and stomach especially was very vascular, softened and 
thickened, and the submucous connective tissue was infiltrated. 

The pseudo-membrane, taken from the epiglottis and examined under 
the microscope, presented an amorphous appearance ; no cells were 
noticed in it, and fibrillation was not distinct ; that from the stomach was 
found to consist almost entirely of cells, the plastic corpuscles of some 
writers, the pyoid of others. The digestive process, so far as the stom- 
ach was concerned, had evidently been almost if not entirely suspended, 
and hence in part the sudden prostration. Diphtheritic gastritis probably 
does not occur without general infection of the system with the diphthe- 
ritic virus. The proper treatment is the use of lime-water or one of the 
solvents of pseudo-membranes, which do not irritate the mucous mem- 
brane. 

Post-mortem Digestion, Softening. 

It is now many years since the attention of the profession was directed 
to disorganization of the coats of the stomach, which is sometimes ob- 
served at post-mortem examinations. John Hunter first ascretained that 
the gastric juice begins to have a solvent effect on the tissues of the stom- 
ach soon after death. Though Hunter erred, when he stated that the 
coats of the stomach are more or less digested in all or nearly all cases, it 
is certain that post-mortem digestion does take place in many cadavers, 
so that a few hours after death the gastric mucous membrane is destroyed 
to a greater or less extent, and occasionally the stomach is perforated or is 
even severed from its connection with the oesophagus. I have seen sev- 
eral examples of this post-mortem digestion in infants. 

Some of the cases of supposed pathological softening of the stomach 
reported by the older observers, seem to have been such as I have de- 
scribed, namely, cadaveric. Yet there are two other kinds of softening 
occurring in children, which are strictly pathological, the one designated 
white, the other, by Cmveilhier, gelatinous. 

White softening of the gastro-intestinal mucous membrane results from 
deficient alimentation. It has been observed only in anaemic and ill-nour- 
ished children. The mucous membrane in such loses its firmness, and is 
easily separated from the subjacent tissue. This disorganization has no 



ITS NATUEE. 681 

connection with any inflammatory process. It is simply a disintegration 
of the mucous membrane in consequence of the low vitality of the patient, 
whether or not there are co-operating causes. I believe that, in a large 
proportion of infants whose systems have been reduced and blood impov- 
erished for a considerable time, the gastro-intestinal mucous membrane 
will be found after death less firm and resisting than in those who have 
been habitually robust. Probably acids which collect in the primae vise 
have much to do with this softening. 

A vague opinion exists in the minds of most physicians as to the nature 
and even appearance of the so-called gelatinous softening of the stomach, 
and the following observations will be cited in order to give a clearer idea 
of it. 

Billard has recorded two cases with his usual minuteness, and adds : 
" What inference shall be drawn from the preceding facts and considera- 
tions ? None other than that the gelatinous softening of the stomach 
consists in a disorganization of the mucous membrane of this viscus, 
caused by an acute or chronic phlegmasia ; that this disorganization is 
characterized by an accumulation of serum in the walls of this organ ; the 
intumescence and gelatinous consistence of the mucous membrane in a 
part usually circumscribed, situated more frequently in the greater curva- 
ture, and about which the membrane exhibits more or less evident traces 
of an acute or chronic phlegmasia. . . . The softening now under 
consideration must not be confounded with another kind of softening" 
(white) " which does not usually succeed an acute phlegmasia." 

Billard believes that, while gelatinous softening results from inflamma- 
tion of the mucous membrane, its proximate cause is an afflux of serum to 
the part in which the disorganization occurs. In one of the two cases 
which he reports, he thinks that the inflammation was acute, but in the 
other chronic, and, therefore, presenting less vascularity. 

West, in speaking of gelatinous softening, says : " Softening of the 
stomach varies in degree from a slight diminution in the consistence of 
the mucous membrane, to a state of complete dirBuence of all the tissues 
of the organ. . . . When the change is not far advanced, the ex- 
terior of the stomach presents a perfectly natural appearance, but on lay- 
ing it open a colorless or slightly brownish tenacious mucus, like the 
mucilage of quince-seeds, is found closely adhering to its interior, over a 
more or less considerable space at the great end of this organ. ' ' 

Cruveilhier says : " This softening often proceeds from the interior to- 
ward the exterior. There is at the beginning simple separation of the 
fibres by a gelatinous mucus, and in consequence the parietes are thick- 
ened and semi-transparent. ... If the transformation be complete, 
the disorganized portions are removed layer after layer, those which 
remain becoming gradually thinner. The peritoneum alone resists for 
some time, but at length it is attacked, worn, and gives way, and per- 



682 SOFTENING. 

foration of the stomach results. The parts thus transformed are colorless, 
transparent, apparently inorganic, completely deprived of vessels, and ex- 
haling an odor resembling that of milk." 

Bouchut remarks : " Softening of the mucous membrane of the stom- 
ach in children at the breast is not a special disease which it is necessary 
to describe by itself. This alteration is always connected with other dis- 
eases, and especially with disease of the large intestine, the knowledge 
of which fact has been too long neglected. It is the consequence of the 
acidity of the liquids contained in the digestive tube of young children, 
liquids which are very acid in the disease we have above referred to." 

Dr. Carswell states that there is a pathological softening of the mucous 
membrane of the stomach, and that when it occurs the symptoms may be 
those of gastritis or enteritis. 

Rokitansky says of this form of softening : ' ' If we consider, in addi- 
tion to the above remarks, the uniform localization of the disease, that in 
none of its stages it presents, either at the point of the softening, or in 
its vicinity, hyperaemic injection or reddening, and that we are still less 
able to demonstrate upon the inner surface of the stomach or in the tissue 
of its coats the products of inflammation, we are constrained to infer the 
non-inflammatory nature of the affection." 

Without extending these extracts, it is seen that eminent authorities not 
only disagree in reference to the cause of gelatinous softening of the 
stomach, but that they also differ in their description of its appearance. 
This diversity of opinion is most likely attributable to the fact that" the 
two kinds of softening have been confounded. Rokitansky and Bouchut 
probably refer to cases of white softening, which occurs in atonic states 
of the tissues in feeble infants, and, therefore, have concluded that soften- 
ing of the stomach is not inflammatory. I believe, from my observations, 
that the opinion of Billard is correct, and that true gelatinous softening is 
the result of gastric inflammation, sometimes chronic, sometimes acute. 
But I have seen appearances which led me to think that the immediate 
causes of the softening continue to operate after death, so that its amount 
is less at the time of death than a few hours subsequently. 

The following case, which was watched by myself with great interest, 
from beginning to end, is an example of inflammatory softening : 

Case. — G. S., male, robust, was born July 10, 1865. The mother not 
being able to suckle the infant, and the danger of artificial feeding in the 
warm months being well understood, a wet-nurse was procured. About 
the 14th of July, this wet-nurse having insufficient milk, another was 
procured temporarily, who suckled the infant till July 20th, when a third 
wet-nurse was engaged, whose child, healthy and thriving, was six weeks 
old. Previously to this time the infant appeared well. It had uniformly 
nursed vigorously and seemed satisfied. 

On the 22d of July, thrush, apparently mild, was observed in the 
mouth, and a powder, supposed to be borax, and labelled such, was ob- 



case. 683 

tained at a drug-store, to be used as a wash for the mouth. This powder 
was afterward ascertained to be alum. Five grains were dissolved in 
as many teaspoonfuls of water, and the mouth of the child was swabbed 
occasionally with it. A piece of linen, folded so as to resemble the tip 
-of a nursing-bottle, was occasionally dipped into the solution, and the in- 
fant was allowed to suck it. The use of the alum was commenced about 
6 p.m. In the first part of the evening the infant slept considerably, and 
of course did not nurse often, but about 8 p.m. it began to be very fret- 
ful, and it then nursed more frequently. It vomited once between 8 and 
10 o'clock p.m. In order to quiet the infant, the tip soaked in the solu- 
tion was often applied to the mouth, but there was scarcely any intermis- 
sion in its crying. Through the night it vomited again once or twice, 
and about the middle of the night had one free liquid stool, which was 
passed with much tenesmus. The countenance of the infant was indica- 
tive of suffering, and its thighs were repeatedly flexed over the abdomen, 
as if that were the seat of its distress. Paregoric in two-drop doses was 
several times given through the night, and flannel soaked with hot whisky 
was applied to the abdomen. 

July 23d. In ignorance of the cause of the child's sickness, another 
wet-nurse was obtained early in the morning, and one sixth of a drop of 
!iq. opii compos, was given every hour, with the effect of inducing a little 
sleep. The tongue was very red, desiccated, and studded with mure 
numerous points of thrush than on the previous day. It now refused to 
nurse, apparently from soreness of the tongue. At each attempt of the 
nurse to induce it to take the nipple, it rubbed the mouth across the 
breast, crying either from pain or disappointment. The alum was not 
used in the latter part of the night of the 22d, but late in the morning of 
the 23d it was resumed, the mistake of the druggist not being discovered 
till midday, when it was estimated that about five grains had been used. 
Occasionally a little of the solution was placed in the mouth with a spoon 
so as to be swallowed, in the belief that the thrush affected the oesopha- 
gus. The infant continued to suffer much during the day, sleeping at 
times a few minutes. Its strength was evidently failing ; respiration reg- 
ular ; pulse about 140 ; its alvine discharges yellow, of natural consis- 
tence and frequency. 

Evening 23d. Surface hot ; it is very restless ; pulse 150 to 160 ; 
tongue dry, intensely red, and dotted with points of thrush. Is treated 
with opiates, a little lime-water, and fomentations. 

24th. In the first part of the day nursed pretty well ; in the latter part, 
<ould be induced to draw the breast only once or twice. The symptoms 
to-day were the same as yesterday, with the exception of greater emacia- 
tion and prostration ; cranial bones uneven, and features pinched. 

25th. Pulse 140 to 148 ; strength rapidly failing, but it cries at times 
loudly. The milk of the nurse, placed in the mouth with a spoon, is 
often held a considerable time before it is swallowed, and deglutition 
seems difficult. Respiration in the first part of the day and previously, 
natural ; in the latter part of the day, accelerated ; dejections natural : 
no vomiting ; appearance of tongue more natural than yesterday. 

26th. Died to-day in a state of collapse at 12^ p.m. The hands were 
cold several hours before death, and the milk given it was regurgitated. 

Autopsy twenty-two hours after death. — Much emaciation ; no rigor 
mortis ; cranial bones uneven ; the upper part of the pharynx injected to 
the extent of about half an inch ; from this point to the stomach mem- 



684: SOFTENING. 

brane healthy ; mucous membrane covering the cardiac two thirds of the 
stomach disintegrated, almost diffluent, and in places detached from the 
subjacent tissue ; mucous coat of the pyloric third of the organ nearly 
healthy ; along the edge of the softened portion the mucous membrane 
was vascular to the extent of a few lines ; the muscular and serous coats 
of the stomach underneath the softened portion were easily torn ; the 
mucous membrane of the small intestine presented in places that degree of 
vascularity known as arborescence ; there was no destruction or softening 
of its mucous membrane ; the colon was healthy ; the stomach was nearly 
empty ; the contents of the small and large intestines were natural in color 
and consistence ; the other viscera were healthy ; in the left pleural cavity 
was about one ounce of transparent serum, and a less quantity in the right 
cavity. 

It cannot be doubted that the softening in the above case was patholog- 
ical. The weather at the time was warm, but the infant was placed on 
ice, and a pan containing ice was kept upon the abdomen. This infant 
died evidently of gastritis, the accompanying inflammation being subor- 
dinate, and in fact insignificant. At first it was a question with me 
whether the alum might not have caused the gastritis, so that the case 
should be properly placed in the category of deaths from swallowing cor- 
rosive substances. In order to determine this point, I administered alum 
daily to two kittens, commencing when they were seven days old. The 
quantity given to each was ten grains daily in two doses for three consecu- 
tive days, and on the two following days five grains. The only uniform 
result noticed was an increased flow of saliva, which washed some of the 
alum from their mouths, and occasionally slight vomiting. There was 
not even any apparent inflammation of the buccal membrane from the 
alum. 

Post-mortem appearances as in the above case, and similar ones re- 
corded by Valleix and others, in which gelatinous softening coexisted 
with evident lesions of gastritis, render it highly probable, if indeed they 
do not demonstrate, that the softening is a result of the inflammation at 
the point where it occurs. 

In Valleix' s twenty -four cases of what he terms fatal muguet, softening 
of the mucous membrane of the stomach was one of the most common 
lesions, and at the same time, which is the point of interest, there were 
signs which showed conclusively the presence of gastric inflammation. 
The common coexistence of the lesions of gastric inflammation, such as 
redness and thickening, with gelatinous softening of the stomach, is cer- 
tainly most reasonably explained on the supposition jthat the one results 
from the other. 

I am not prepared to accept nor reject the theory of Billard, that the 
immediate cause of the softening is the afflux of serum, nor that of Bou- 
chut, that it is an excess of acid. 

It has been said that M. Baron was able to diagnosticate gelatinous 



NON-INFLAMMATORY DIARRHCEA. 685 

softening. The symptoms are those of the severe forms of gastritis. 
The vomiting, great pain, restlessness, sudden and progressive emaciation, 
and, finally, collapse preceding the fatal result, without sufficient diarrhoea 
to cause the rapid sinking, are the symptoms on which the diagnosis is 
based. The treatment should be directed to the gastritis. 



CHAPTEE VII. 

DIARRHCEA. 

Diarrhcea is frequent during the whole period of infancy. The 
French writers describe several varieties, according to the character of the 
evacuations, as acescent, mucous, and serous. M. Rostan even describes 
fourteen distinct kinds. But the tendency of medical science in these 
modern times is to simplify the nomenclature of diseases — to describe 
under a single name those affections which are essentially the same though 
differing somewhat in their features. Now, all the forms of diarrhoea in 
the infant may be so grouped as to reduce the number to not more than 
three or four. In this way repetition and prolixity are avoided, as well as 
an unnecessary refinement. 

Non-Inflammatory Diarrhoea. 

The most common form of diarrhcea is that enunciated in our heading, 
which writers sometimes designate by the term simple or spasmodic. 
But often a diarrhoea which is non-inflammatory at first, becomes a 
catarrh. Thus the simple diarrhoea of infancy may become an entero- 
colitis from the continued use of improper diet. 

Causes. — These are various. Conditions or agencies which have no 
appreciable effect in the adult often increase the number of evacuations in 
young children. Food which imperfectly digests, and some of which 
perhaps ferments, stimulates the intestinal follicles to excessive secretion, 
and increases the peristaltic movements by its vitiating property, thus 
causing diarrhoea. Too frequent and abundant feeding is another cause, 
especially in young infants, some of whom may vomit the surplus food 
and remain well, but others do not. Food which cannot be assimilated 
becomes an irritant in consequence of fermentative changes, and produces 
frequent and unhealthy evacuations. The late Dr. James Jackson, of 
Boston, directed attention to this cause of diarrhoea in his Letters to a 
Young Physician. 

The mother's milk or the milk of the wet-nurse may disagree, either 
from some temporary derangement of her system, or continued ill-health, 



686 NO N -INFLAMMATORY D I A R R H (E A . 

or from causes which arc not understood. Non-inflammatory diarrhoea 
in the nursling* is the immediate result, with perhaps subsequent inflam- 
mation. The milk in these cases frequently contains the elements of 
colostrum. 

Fright or strong mental impressions will also in some children increase 
the number of evacuations. This cause being transient, the diarrhoea 
soon subsides. 

Another cause is exposure to cold. Children who are insufficiently 
clothed in the winter season, who are taken from a heated room into a 
cool one without sufficient precaution, or who lie uncovered at night, are- 
very subject to diarrhoeal attacks from the impression of cold on the 
sy stern. 

The cause of non-inflammatory diarrhoea may exist in the child itself. 
In some children the evolution of the teeth is attended by a relaxed state- 
of the bowels, which ceases when the gum is pierced. Worms in the in- 
testines may also operate as a cause. Diarrhoea is occasionally salutary 
within certain limits, and of course it is not strictly correct to call it a 
disease when it is a means of relief. If occurring from excessive or irri- 
tating ingesta, it is obviously conservative. 

Symptoms. — Non-inflammatory diarrhoea may come on suddenly ; at 
other times there are precursory symptoms continuing for some days. 
Whether or not there be antecedent symptoms depends chiefly on the 
cause. If this be exposure to cold, or the use of improper aliment, it 
commonly occurs immediately. 

Among the prodromic symptoms sometimes present are restlessness,, 
disturbed sleep, transient abdominal pains, nausea or vomiting, and other 
symptoms of indigestion. The stools in simple diarrhoea differ much in 
color and consistence in different cases, and perhaps at different periods 
in the same case. In infants they are apt to be green. This color, which 
is a source of anxiety to the inexperienced, and especially to the parents,, 
is often produced by trivial causes. Slight indigestion will produce it, 
and so will excess of food, even when bland and unirritating. The stools 
in infantile diarrhoea often contain particles of coagulated casein, but in 
children advanced beyond the period of first dentition, they do not differ 
materially in appearance from the evacuations of the adult. They are 
usually passed easily, but if they be acid or in any way irritating, there 
may be more or less tenesmus, especially in infants. Sometimes before 
the evacuations, there is a sensation of fulness in the abdomen. In that 
form of diarrhoea which has been designated acescent, not only are the 
stools acid, but matters vomited have an acid odor, and give an acid 
reaction. 

During the quiet hours of sleep, when no food and drinks are taken,, 
the diarrhoea diminishes. If the complaint be slight, there is little thirst ; 
but if the stools be frequent and thin, especially if they approach the 



ANATOMICAL CHARACTERS. 687 

watery character, the patient is thirsty. The appetite varies, the tongue 
is moist, and covered with a light fur, and there is often more or less 
meteorism, but no abdominal tenderness. 

The features in this disease are pallid. In a few days, if the evacua- 
tions continue, there is evident loss of weight and flesh. The rotundity 
of the limbs is gradually lost, and the tissues become soft and flabby. 
But in most cases, when the malady has reached this stage, its original 
character is lost, and it has become inflammatory. 

There is no constant fever in true non-inflammatory diarrhoea. Some- 
times the pulse is accelerated in the latter part of the day, but usually 
only for a short time. 

Certain epiphenomena, as Barrier terms them, occur at times in non- 
inflammatory as well as in inflammatory diarrhoea, as for example a sym- 
pathetic cough, or, which is more serious, cerebral complications. Con- 
vulsions or stupor, indicating the supervention of spurious hydrocephalus, 
may occur in either form of diarrhoea. This disease is described else- 
where. 

Anatomical Characters. — It is obvious from the nature of this mal- 
ady that it is attended by little or no structural changes perceptible to the 
anatomist. In cases supposed to be non-inflammatory, which have ended 
fatally either from the diarrhoea or an intercurrent disease, the most 
marked lesioDS observed have been more or less tumefaction of the intesti- 
nal glands, with perhaps diminished firmness and resistance of the mucous 
membrane. Cases like the following, which have usually been regarded 
as non-inflammatory, are not infrequent, but it seems to me probable that 
in at least a certain proportion of such cases the intestinal follicular appa- 
ratus has passed beyond the physiological state of an exaggerated func- 
tional activity, and that the disease should be designated a catarrh or 
inflammation. Inasmuch as non-inflammatory diarrhoea, if protracted, is 
very apt to become inflammatory, it is often difficult to determine whether 
the malady has undergone this change, even when the case is fatal, and 
post-mortem inspection is allowed. 

On the 7th of July, 1865, a foundling, one month old, died at the In- 
fant Asylum. It was much emaciated, with eyes sunken and features 
pinched, at the time of its death. It was wet-nursed toward the close of 
its life, but the nurse's milk was insufficient. It did not vomit ; did not 
have any marked acceleration of pulse (128 per minute), and its evacua- 
tions were about four daily, and thin. The stomach and intestines were 
pale throughout. The solitary glands, particularly those in the colon, 
and the patches of Peyer, were tumefied so as to be visible, and somewhat 
raised above the surrounding surface. There was probably slight thicken- 
ing of the mucous membrane, and tumefaction of the muciparous folli- 
cles, but these changes were not clearly ascertained. 

Niemeyer, with others, describes even the mildest forms of diarrhoea 



688 NON-INFLAMMATORY DIARRHffiA. 

under the term catarrhal inflammation, and he appears to consider the 
transient effects of a purgative as an incipient catarrh. But it seems to 
me preferable, in the present state of pathological knowledge, to regard 
all those diarrhoeas which immediately abate with the removal of the 
cause, and which are attended by no marked anatomical change, as non- 
inflammatory. 

Prognosis. — In a large proportion of cases, non-inflammatory diarrhoea 
is not dangerous. With the adoption of suitable measures to remove the 
cause, and the use of medicines to control the discharges, the patient re- 
covers. The remark already made may be repeated here, that occasion- 
ally diarrhoea is salutary within certain limits, as when there is a foreign 
substance in the intestines, either irritating mechanically or by its chemi- 
cal properties, and which the diarrhoea serves to remove. 

The danger arises from complications, as spurious hydrocephalus, or 
from the emaciation and exhaustion, or from its eventuating in inflamma- 
tion. 

If the rotundity of the figure and firmness of the tissues be preserved, 
showing that alimentation is still sufficient, and no complication arise, 
the diarrhoea is not as a rale dangerous. In infants that over-nurse and 
do not vomit the surplus milk, the evacuations are sometimes green and 
frequent, and yet fulness of figure is preserved, and the development of 
the body proceeds as usual. On the other hand, diarrhoea attended by 
emaciation or softness or flabbiness of the flesh, involves danger, and 
requires immediate treatment. 

Treatment. — It is necessary, in order to treat diarrhoea in infancy and 
childhood successfully, to ascertain the cause, and, so far as possible, to 
remove it. It is not till the cause ceases to operate, that we can expect a 
satisfactory result from medication. The disease may be temporarily re- 
lieved by medicine, but it usually returns at once when treatment is 
omitted, unless the patient be removed from the influence of the agencies 
which produce it. These remarks are especially applicable to the diarrhoea 
of infants. With them very generally, when affected with this complaint, 
there is some fault as regards the quantity or quality of food. Attention 
to this matter will show the need of a change of wet-nurse, or, if the in- 
fant be spoon-fed, a change in the character of its food or the mode of 
preparation or even in the quantity given. Sometimes by change in the 
diet, and the adoption of hygienic measures, the complaint ceases, so as 
to require no medication. If medicines be needed, and the symptoms 
are not urgent, it is occasionally advantageous to commence treatment by 
the use of some of the milder purgatives in small doses. In the infant, 
in whom the dejections are so generally acid, an alkaline laxative, or a 
laxative conjoined with an alkali, often has a good effect as preliminary 
treatment. Half a teaspoonful to one teaspoonful of castor oil, or a pro- 
portionate dose of calcined magnesia, removes any acid or irritating sub- 



TREATMENT. 

stance from the intestines, and is followed by a diminution in the num- 
ber of stools. The improvement, however, without subsequent treatment, 
is usually only for a day or two. In this city a purgative dose of castor 
oil is often given as a domestic remedy in infantile diarrhoea, the benefi- 
cial effect from it having popularized its use for this purpose. Trousseau 
usually gave Rochelle salts, but this medicine is too severe and dangerous 
for the treatment of infantile diarrhoea, especially in warm months. 

If there have been previous constipation, and the diarrhoea have just 
commenced, a purgative is obviously indicated. West says : " Provided 
there be neither much pain nor much tenesmus, and the evacuations, 
though watery, are foecal, and contain little mucus and no blood, very 
small doses of the sulphate of magnesia and tincture of rhubarb have 
seemed to me more useful than any other remedy : 

"R. Magnesia? sulphatis, 3j ; 
Tinct. rhei, 3j ; 
Syr. zingiberis, 3j ; 
Aquse carui, 3 ix. Misce. 
3 j ter die for children one year old ; 

and I seldom fail to observe from it a speedy diminution in the frequency 
of the action of the bowels, and a return of the natural character of the 
evacuations. ' ' 

In diarrhoea of infants, due to indigestion, and attended by acidity, the 
following prescription is sometimes useful. By improving digestion and 
correcting acidity, it has a beneficial effect on the diarrhoea. The cases 
are, however, in my experience exceptional in which this is the proper 

remedy : 

R. Pulv. ipecacuhanse, gr. ss ; 
Pulv. rhei, gr. ij ; 
Sodae bicarb., gr. xij. Misce. 
Divide in chart. No. xij. One powder every four to six hours to an infant one 
year old. 

The effect of laxative medicines, employed for the purpose of correcting 
the functions of the gastro-intestinal surface, is uncertain. If no improve- 
ment results from their use within two or three days, they should be 
omitted. "We must rely on astringents, opiates, and, in infants, also on 
alkalies. If the symptoms be urgent, if the evacuations be frequent and 
exhausting, these agents should be employed from the first. Much harm 
is often done, and precious time lost, by prescribing laxative mixtures 
when opiates and astringents are required. I have known them to aggra- 
vate the complaint, when, by change of measures, immediate improve- 
ment followed. The majority of cases of non-inflammatory diarrhoea, at 
the period when the physician is called, are best treated by the use of as- 
tringents and opiates exclusively, proper directions at the same time being- 
given in reference to the diet and hygienic management. 
44 



690 INTESTINAL CATARRH OF INFANCY. 

In the diarrhoea of infants the compound powder of chalk and opium 
is an excellent medicine, containing, as it does, an astringent with the 
opiate and alkali. It may be given in doses of three grains, to a child 
one year old, every three hours. I ordinarily employ it with double its 
quantity of subnitrate of bismuth, and know no better remedy for ordi- 
nary cases. The following is a convenient formula for administering sub- 
stantially the same medicines in the liquid form : 

5. Tinct. opii deodorat., gtt. xvj ; 
Bismuth, subnitrat. , 3 ij ; 
Syr. simplic. , 5 ss ; 
Mistur. cretse, §iss. Misce. 
Shake well and give one teaspoonful from three to four hours. 

In a large majority of cases I employ this prescription, or one similar to 
it, from my first visit. If the patient be not relieved by the opiate, alkali, 
and bismuth, and by proper regimen, in all probability inflammation of 
the intestinal mucous membrane is present. In patients over the age of 
two or three years simple diarrhoea approaches in character that of the 
adult, and the treatment appropriate for the adult is proper in these cases, 
allowance being made for the difference of age. In infants, in whom this 
disease, if protracted, is very liable to eventuate in spurious hydrocepha- 
lus, alcoholic stimulants are often required at an early period, on account 
of the prostration and feeble power of endurance. 



CHAPTER VIII. 

INTESTINAL CATARRH OF INFANCY. 

It is customary with writers to treat of inflammation of the small and 
large intestines in infancy as a single disease, for the following reasons : 
First, the symptoms of colitis, at this period of life, do not ordinarily 
differ, in any marked degree, from those of enteritis. The tormina, tenes- 
mus, and abdominal tenderness, which characterize colitis in childhood 
and adult life, are ordinarily lacking, or are not appreciable by the ob- 
server ; and the muco-sanguineous evacuations are oftener absent than 
present. On account of this absence of symptoms, Bouchut says : 
" Dysentery is a very rare disease among young children. Its existence 
might even be denied, if it had not been observed at the period of some 
severe epidemics of dysentery." If Bouchut refers, by the term dysen- 
tery, to the ordinary phenomena of that disease, his remark is correct ; 
but, as regards the lesions, it is erroneous, for colitis is a common infan- 
tile malady. Billard, after analyzing eighty cases of intestinal inflamma- 
tion in infants, says : " From this calculation, it is evidently very diffi- 



CAUSES. 691 

cult to make a correct diagnosis of inflammation of the intestinal tube in 
sucking infants, yet it would seem as if the proper signs of enteritis or 
ileitis were the rapid tympanitis of the abdomen, the diarrhoea, accom- 
panied with vomiting ; while in colitis, diarrhoea alone, without tympa- 
nitis, is the most frequent. ' ' And again : * ' In consequence of the impos- 
sibility we have found to exist of tracing with exactitude the series of 
symptoms proper to inflammation of the different portions of the digestive 
tube, we shall content ourselves with presenting an analytical sketch of 
the causes, symptoms, and ordinary course of inflammation of the mucous 
membrane of the intestines in general." 

The frequent absence of any pathognomonic symptom or sign, by 
which to determine the exact seat of intestinal inflammation in the infant, 
is admitted by recent observers as well as Billard. 

The second reason why intestinal inflammation in the infant is described 
as a single disease is, that enteritis and colitis, in the majority of cases, 
coexist. This will be seen when we come to speak of the anatomical 
characters. 

Intestinal catarrh is one of the most common and fatal of infantile 
maladies. It is the great summer epidemic of the cities, in this country. 
Unfortunately for a correct understanding of its prevalence and mortality 
in this city, and perhaps elsewhere, it is very generally in the summer 
months when obstinate, and especially when fatal, called cholera in- 
fantum, although, in its symptoms and nature, it is very different from 
that disease. It usually has a mild beginning and is often protracted, 
while true cholera infantum begins abruptly, is characterized by violent 
symptoms, and rapid and extreme exhaustion. 

The 1500 fatal cases of so-called cholera infantum, reported every sum- 
mer in this city, are, with now and then an exception, cases of inflamma- 
tion, generally protracted. Moreover, the excess of reported cases of in- 
fantile marasmus, in the second half of the year, over those reported in 
the first half, should be added to the statistics of intestinal catarrh, for 
this excess, which is noticed every year in the mortuary tables of this 
city, is due mainly to the death of those wasted infants who have lingered 
with entero-colitis from the summer months. Their marasmus is simply 
a result of the protracted inflammation. 

Causes. — Catarrh of the intestines in infancy, I have said, is most fre- 
quently a summer malady — at least, in the cities. Occasionally it is ob- 
served in the winter, and it is then, when not due to error of diet, pro- 
duced by exposure to cold. Infants who are taken from warm to cold 
rooms, or into the open air, by heedless nurses, or who sleep uncovered 
at night, are especially liable to it, whether residing in the city or coun- 
try. In cases occurring from such exposure the inflammatory process 
may not commence suddenly. There is often a premonitory stage of 
simple diarrhoea, the first effect of the impression of cold. 



692 INTESTINAL CATARRH OF INFANCY. 

The influence of the summer season in causing intestinal catarrh in 
young children is forcibly shown by the statistics of this city (New York), 
in which I found from the mortuary tables which I consulted a few years 
since, that during five years over 9000 young children, chiefly infants, 
perished from the diarrheal maladies between the first of June and last of 
October. Indeed there is no disease except tuberculosis so prevalent and 
fatal as infantile entero-colitis, during the period of its epidemic occur- 
rence in the summer months ; and so far as I have been able to ascertain, 
the same remark is applicable to most of the other large cities of the 
"Union. 

The epidemic commences about the middle of May. From this time 
there is a gradual increase in the number affected, till the months of July 
and August, when the disease attains its maximum prevalence and mortal- 
ity. During the months of September and October, the number of seiz- 
ures and of deaths gradually abates till the epidemic character is lost. It 
is thus seen that the prevalence of intestinal inflammation of infancy in 
the city bears a close relation to the degree of summer heat. 

In looking for the causes of this disease of the summer season we must 
evidently consider those conditions which are peculiar to the hot months, 
or are more operative in them than at other times. The one peculiar to 
the summer which is most apparent is the increase of the atmospheric 
heat, but that this in itself does not cause the summer complaint is evi- 
dent from the fact that in sparsely settled country towns there is often 
equal elevation of temperature, for many weeks, but with continued 
healthiness. The atmospheric conditions which render the summer 
months so detrimental to young children in the cities must be the noxious 
products which the heat generates, and which, diffused through the air, 
contaminate it. In the poor quarters of the cities more than anywhere 
else, those conditions occur which render the atmosphere impure and un- 
suitable for respiration. Hence those diseases which foul air produces 
occur most and present their severest type in those quarters of the city 
where the destitute, ignorant, and degraded congregate. One accustomed 
to the pure air of the country would hardly believe how stifling and poi- 
sonous it becomes during the hot summer days and close summer nights 
in and around the apartments of the city poor. Among the causes of 
this foulness of the air, and the consequent sickness which it entails, may 
be mentioned too dense a population and the occupancy of small rooms 
by large families, rigid economy, and ceaseless endeavor to make ends 
meet, so that in the absorbing interest sanitary requirements are sadly 
neglected. Adults of such families, and children of both sexes, as soon 
as they are old enough, engage in laborious and often dirty occupations. 
They seldom bathe, and often wear for days the same undergarments foul 
with perspiration and dirt. The intemperate, vicious, and indolent who 
always abound in the quarters of the city poor are notoriously filthy in 



causes. 693 

their habits. Children old enough to be in the streets and adults away at 
their oocupations escape to a great extent the evil effects of impure air 
produced by such mode of life, but the infantile population always suffer 
severely. 

Families thus living, being habituated to foul air and odors, often do not 
appear to notice them, and neglect to obtain a purer air by open windows 
and doors. To add to the insalubrity, dirty and worn-out garments and 
utensils of various sorts collect under their beds and in their closets. 
Waste products of the table and excrementitious substances are allowed 
to stand for hours in the room occupied by the family, or in the attached 
bedroom, undergoing fermentative changes. 

With such disregard of sanitary requirements as might be expected the 
halls, stairways, areas, and alleys within and around the domiciles ordi- 
narily show a similar culpable neglect. They are seldom kept clean when 
families in their rooms are so slovenly and dirty, being the receptacle to 
a greater or less extent of rejected and waste animal matter. The fate of 
the infant compelled to breathe day after day an atmosphere which such 
uncleanliness produces is evident. It pines away, becomes pallid, per- 
haps exhibits strumous ailments, and in the hot weather is apt to have 
diarrhcea. At least this is a very common result. If it do not suffer in 
the way mentioned, it is because there are countervailing circumstances, 
an unusually robust constitution, or it is kept much of the time in the 
open air. 

It is true that in our large cities health boards have done much to miti- 
gate the evil alluded to, producing in families more regard for cleanliness. 
Still, even with vigilant health and police boards, it is impossible to obtain 
sufficient purity of air, so essential to infantile health, when families are 
totally indifferent to hygienic requirements through ignorance, vice, in- 
temperance, or poverty. No city in the United States has probably ex- 
perienced so great sacrifice of infantile life in times gone by from personal 
and domiciliary neglect as New York, of which I have been an eyewit- 
ness, but the evil, which we have experienced in the city in an aggravated 
form, exists in all our large cities. 

The exact changes which the atmosphere undergoes, and the noxious 
principles diffused in it, which render it unwholesome to man, have 
been partially ascertained. We know that the air is the medium of com- 
munication of most of the infectious maladies, though the agents by which 
these maladies are propagated are so subtle that they have for the most 
part escaped detection. We know that when our senses can detect noth- 
ing wrong the air frequently contains principles which produce the most 
violent and fatal diseases ; and that impurities in the air arising from ani- 
mal exhalations and excretions, and from decaying organic matter, are a 
common and potent cause of diarrhoeal maladies is well established. The 
most violent and fatal disease to which the human race in modern times is 



694 INTESTINAL CATARRH OF INFANCY. 

liable, namely, Asiatic cholera, belongs to the class of diarrhoeas, and 
numbers its chief victims where the air is most tainted by effluvia from 
filthy streets and domiciles. The ravages of this disease chiefly occur 
where population is most dense and measures to insure personal and 
domiciliary cleanliness and purity of air are neglected. I might men- 
tion striking and pertinent examples which I witnessed in New York 
during the cholera of 1854, which ravaged chiefly the families living 
along the dirty streets and in tenement houses, and those whose occupa- 
tions necessitated the respiration of a foul atmosphere. Moreover, an in- 
teresting fact often observed in the dirty sections of the city, and in the 
crowded tenements where the air was sensibly impure, daring the epi- 
demic of that year and in similar epidemics of cholera, deserves men- 
tion, namely, that persons exposed to the anti-hygienic conditions which 
predispose to cholera were apt to have diarrhoea very similar to the ordi- 
nary infantile summer complaint, whether or not they afterward had a 
true choleraic attack. 

But each summer furnishes abundant direct observations showing that 
foul air sustains a causative relation to infantile diarrhoea. Several years 
ago, while serving as sanitary inspector for the Citizens' Association, my 
attention was particularly arrested by the state of one of the streets which 
was not sewered, though supplied with Croton water, and was densely pop- 
ulated on either side by families mainly of foreign birth. The ashes and 
garbage were placed in barrels and boxes along the sidewalks, or thrown 
at random in the street. The Croton water and the house-slops flowed 
into the gutters and mixed with the refuse and excrementitious matters 
from the tables and bed-chambers of the houses, while the interior of 
some of the houses and the spaces around them were in a similar filthy 
state. There was no Health Board at that time to enforce sanitary regu- 
lations, and any attempt to abate the nuisance of a filthy street in the ab- 
sence of a sewer, and with the presence of a large and ignorant popula- 
tion, could be only partially successful. Consequently this street, with 
gutters constantly wet and containing decaying organic matter, was 
during the hot months one of the sickliest in the district which was 
assigned to me. The noxious gases emanating from such a source told 
fearfully on the general health, and a house-to-house visitation revealed 
the fact that diarrhoea was extensively prevailing among the infants thus 
exposed, and was the chief cause of the deaths during July and August. 
In another locality, occupied by tripe dealers and a low class of butchers, 
who carried on fat and bone boiling at night, the air was so foul after 
dark that the peculiar impurity which tainted it I could distinctly notice 
in the taste for a considerable time after a nightly visit. In the street 
where these nuisances existed, and in adjacent streets, a choleriform diar- 
rhoea was most destructive to infantile life. 

It is impossible to isolate and determine all the deleterious gases of 



causes. 695 

which the atmosphere of a city is composed ; but this we know, that in 
streets which are not properly cleaned of refuse matter and in and around 
dwellings occupied by the destitute and degraded who disregard sanitary 
laws, the air becomes so foul during the hot months, when chemical 
changes are most active, as to be quite perceptible and offensive to the 
visitor. The common practice of watering streets which are dirty only 
adds to their unwholesomeness, for organic matter, whether in masses or 
triturated to powder by passing vehicles, is comparatively harmless when 
dry, but yields poisonous gases in abundance when moist and undergoing 
decomposition. 

The amount of carbonic acid present in the air is regarded as a pretty 
correct test of the degree of its impurity. This gas is always present in 
the atmosphere, but, when it exists in abnormal quantity, it is associated 
with other poisonous gases, generally in quantities proportionate to its 
own, but which cannot be so readily isolated. Its quantity is always 
greater in the city than in the country, and in badly ventilated dwellings 
and public halls it frequently accumulates so as to be decidedly hurtful 
to those who respire it. Pure air, it is estimated, contains three to four 
parts by measure of carbonic acid in 10,000 of air, but Pettenkoffer 
found 72 parts in a school-room two hours after the school was convened, 
-and W. R. Nichols found 32 parts of the gas in 10,000 in a room which 
had been occupied by a Sunday-school for one and a half hours, while 
Baring discovered 120 parts in the rooms of a Volks-schulen. Now, it is 
admitted that carbonic acid may be largely increased in an atmosphere 
otherwise pure without causing serious consequences, but if this increase 
be from respiration, cutaneous exhalation, and from decomposition of 
organic matter, the carbonic acid is associated with other gases which are 
exceedingly poisonous. Pettenkoffer remarks, and those who have inves- 
tigated the subject agree in the general statement, "Air is bad and im- 
proper for continuous use when it contains, in consequence of respiration 
and perspiration, more than one part of CO 2 in 1000, and a good air for 
chambers in which a person may remain for a long time in a state of 
health and comfort contains no more than .... 7 parts in 
10,000." The gases which are found with carbonic acid in occupied 
rooms have been enumerated by Parks as follows : Carburetted hydrogen, 
sulphurous acid, sulphuric acid, sulphuretted hydrogen, phosphuretted 
hydrogen, and ammoniacal vapors. 

In addition to these gases, which it will be perceived are very detri- 
mental to animal life, the air contains motes of organic matter, often in 
considerable quantity, as every one has noticed by viewing a sunbeam in a 
darkened room. Among these motes in an occupied room, the micro- 
scope discovers vegetable debris and various animal substances, as frag- 
ments of epidermic cells. 

Eulenberg discovered many animal and vegetable fragments and forms 



696 INTESTINAL CATAEEH OF INFANCY. 

in the air which he examined, some of them evidently having been wafted 
from long distances. The air of the city contains a vastly greater 
quantity of these organic particles than the air of the country, as is evi- 
dent from the dust which is incessantly settling on furniture, and the dirt 
which gathers in neglected and unfrequented streets and lanes in the 
course of a few weeks. 

These many impurities, solid and gaseous, in the air of the city, 
together with the countless monads, vibriones, and bacteria, just visible 
under high powers of the microscope, which spring into existence wher- 
ever decomposition is going on, afford sufficient explanation of the 
greater insalubrity of the city than of the country. Precisely in what 
way impurities in the air cause infantile diarrhoea is not known, though 
there are so many striking examples of the fact. Murchision states that 
twenty out of twenty-five boys in a school-room were affected with vomit- 
ing and purging from inhaling the effluvia from the contents of an old 
drain near the play-room. Perhaps the gases form certain combinations 
in the system which are purgative. Sulphuretted hydrogen, one of the 
most poisonous of these gases, is believed by those who have investigated 
the subject to be changed into sulphuric acid in the air, and we know 
that this acid, if it unite with a potassium or sodium base, forms a purga- 
tive salt. Medical students are familiar with a similar fact, that the foul 
air of a dissecting-room causes diarrhoea, gases from animal decomposition 
being sufficient to produce it in those otherwise healthy. 

Another important cause of the summer diarrhoea is the diet. A large 
proportion of those who every year fall victims to this malady would 
doubtless escape if the feeding were exactly proper. The following facts 
relating to this subject are substantiated by the experiences of each sum- 
mer : Infants weaned before the proper time are very liable to the sum- 
mer diarrhoea, and the younger the infant thus artificially fed the greater 
the liability. In New York a large proportion of the infants, under the 
age of six months, when the warm weather begins, if deprived of the 
breast-milk, take diarrhoea, and unless removed to the pure air of the 
country, where also fresher and better cow's milk can be obtained, per- 
ish. Aware of these facts, the managers of the infant and foundling asy- 
lums employ, so far as possible, wet-nursing for the infants in these insti- 
tutions, although it greatly increases the expense. Before the establish- 
ment of the Health Board in New York, when the air in and around the 
city was much more foul than at present, from the common disregard of 
sanitary laws, it was seldom that an artificially fed infant under the age of 
six or even ten months, residing within the city limits, escaped the sum- 
mer diarrhoea. So fatal was this malady among bottle-fed infants in 
those days, when both atmospheric and dietetic causes were operative in 
a high degree, that when I was appointed physician to the foundlings, 
about fifteen years since, I found it the common belief among the nurses 



causes. 697 

and others, that all of them would sooner or later die. One was pointed 
out as a curiosity, since it had been several months in the institution, and 
was still alive. Such mortality was remarkable, for the foundlings of the 
city at that time exceeded one thousand annually. They were consigned 
to the care of the pauper women in the almshouse, who were mostly old, 
infirm, and filthy in their habits and apparel. Their beds, in which the 
foundlings were also placed, were seldom clean and properly aired, or 
washed, and under the beds were various garments and utensils which 
they had brought with them, as their possessions, from their miserable 
abodes in the city. With such surroundings the air which these infants 
breathed night and day was obviously totally unfit, while the diet was not 
less unsuitable, for it was prepared by these degraded women from such 
milk and farinaceous food as the Commissioners of Charities furnished the 
almshouse. The common disease of these foundlings was diarrhoea, and 
the cause of the frightful loss of life was obviously both dietetic and 
atmospheric. 

Such waste of life was the legitimate result of the conditions, for it oc- 
curred under a law of general applicability that whenever the diet is im- 
proper and the air foul, infants pine away and die. What occurred with 
these foundlings is repeated every summer in the domiciles of the city 
poor, wherever infants are improperly fed, and the air which they breathe 
is loaded with poisonous gases, produced by overcrowding or the pro- 
longed action of atmospheric heat on the decaying organic substances. 

Dietetic errors by which diarrhoea is produced, and if they are repeated 
intestinal catarrh results, are numerous. The reader is referred to the 
chapter relating to diet, for a statement of the kind and variety of food 
which is suitable for different ages in infancy and childhood, departure 
from which is apt to cause indigestion and diarrhoea, and therefore to act 
as a potent cause of the malady which we are now considering. 

But there is one dietetic cause of infantile diarrhoea operating not only 
in the hot months, but at other times also, to which I wish to call atten- 
tion, and to which allusion has already been made in our remarks on non- 
inflammatory diarrhoea. The late Dr. James Jackson, of Boston, pointed 
out the fact that too frequent and too prolonged nursing, even when there 
is no fault in the milk, is a common cause of diarrhoea. Infants some- 
times overnurse, and they may or may not vomit the surplus food. If 
they do not, the portion of the food which is not digested undergoes fer- 
mentative changes, becomes an irritant, and causes green and too frequent 
stools, which contain particles of undigested casein, and other ingredients 
of milk. If such infants fret, as they often do, from indigestion, they are 
applied still more frequently to the breast. Gases and acids form in the 
stomach and intestines, and in consequence of the irritation thus pro- 
duced, intestinal catarrh may result. Too frequent feeding with artificial 
food often produces the same result. 



698 INTESTINAL CATARRH OF INFANCY. 

In these various ways dietetic errors operate as the second factor in the 
causation of the summer diarrhoea, and they are not infrequently the im- 
mediate exciting cause. 

It is a common belief that dentition is one of the chief causes of infan- 
tile diarrhoea, whether inflammatory or non-inflammatory. There is, in- 
deed, great liability to this disease during the period of dental evolution. 
The following statistics, which were mostly collected during my term of 
service in one of the city dispensaries, and which comprise all the cases of 
diarrhoea under the age of about five years which were brought into that 
institution for treatment during the summer months of my attendance, 
show the preponderance of cases in the time of teething. The diarrhoea 
in most of these patients was evidently inflammatory. 

Stage of Dentition. Number of Cases. 

No teeth, 47 

Cutting incisors, 106 

" anterior molars, 41 

" canines, 40 

last molars, . . . . . . . 20 

Having all the teeth, 28 

Total, 282 

It is seen that although a large majority of the above cases occurred 
during dental evolution, yet in a certain proportion, about one in four, 
teething could not operate as a cause. My own opinion is that dentition 
does not sustain any causal relation to the intestinal catarrh of infancy, or 
if any it is indirect and unimportant. 

An important predisposing cause of intestinal inflammation in infants is 
the rapid development of the intestinal crypts and follicles. This devel- 
opment, which increases the liability to organic diseases of the intestines, 
is coincident with dentition. Another important cause remains to be 
notified, namely, weaning. Weaning is a subject to which less attention 
is given than its importance demands. The summer succeeding the 
change of diet is always in the city a time of great danger to the infant 
from diarrhoeal affections. Mothers uniformly speak with dread of the 
second summer. In this city, nearly every infant taken from the breast 
between the months of April and October very soon becomes affected 
with diarrhoea which, if not inflammatory in its commencement, soon be- 
comes such. Weaning in the cool months involves less danger, but even 
then the succeeding summer is one of peril. I have memoranda of the 
time of weaning in forty- six infants who were affected with diarrhoea ap- 
parently from its duration and obstinacy of an inflammatory character. 

Weaned in spring or summer, . . . .35 
" " autumn or winter, . . . 11 

46 



AGE. 699 

The reader is referred, for other particulars in reference to weaning, to 
the chapter devoted to this subject. 

The above facts and statistics, to which more might be added, suffice 
to show the causative relation of foul atmosphere and injudicious feeding 
to the intestinal inflammation of infancy. 

This catarrh also occurs as a complication of certain diseases, especially 
the eruptive fevers. It is the opinion of some, that in measles and scar- 
latina there is often mild catarrh of the intestinal mucous membrane, 
coexisting with the eruption upon the skin, and disappearing with it. But 
in a proportion of cases, most frequently in measles, a more intense in- 
flammation arises, constituting a serious complication. The peculiar in- 
testinal catarrh in typhoid fever is well known. 

Age. — My observations in reference to the age at which this disease 
occurs were made in the summer months, and, therefore, relate to the 
summer epidemic. The cases embraced in the following table were 
nearly all observed between the months of May and October inclusive : 

Age. Number of Cases. 

5 months or under, 58 

From 5 months to 12, 212 

" 12 " 18, 174 

" 18 24 93 

" 24 36, 36 

Total, 573 

This table shows that the infant under the age of six months is less lia- 
ble to entero- colitis than between the ages of six months and two years. 
The small comparative number, however, affected under the age of six 
months, I attribute to the fact that most of the infants under this age 
were wet-nursed. Observations made in the institutions of this city in 
which foundlings are received show that, the younger the infant is, the 
more liable it is to be affected with this disease, under unfavorable condi- 
tions of atmosphere and diet. Thus, in the New York Infant Hospital, 
prior to the adoption of wet-nursing, a large proportion of the foundlings 
received died of well-marked entero-colitis in the first and second months, 
and very few lived till the age of six months. A similar fact was ob- 
served in the New York Infant Asylum in Bloomingdale.* During my 
term of service in this institution I preserved notes of forty-nine fatal 
cases, which I diagnosticated entero-colitis, and in many of which post- 
mortem examinations were made. Of these cases eighteen were one month 
old or under, fifteen from one month to three, eight from three to six, 
and only eight over the age of six months. 

* This institution was discontinued within a year after its establishment, all 
connected with it becoming discouraged from the great mortality of the found- 
lings, who were chiefly bottle-fed. 



700 INTESTINAL CATARRH OF INFANCY. 

Symptoms. — Intestinal catarrh in the infant is announced by the occur- 
rence of lassitude, febrile movement, and perhaps fretfulness, soon fol- 
lowed by diarrhoea. The stools are thinner than in health, and their 
color is yellow, brown, or green. Infants having a milk diet are apt to 
pass green and acid stools containing particles of undigested casein. 

The tongue in the commencement of this malady is moist and covered 
with a light fur. At a more advanced stage it may be moist, but is often 
dry, and in dangerous forms of the malady accompanied by prostra- 
tion, the buccal surface is red, the gums more or less swollen and some- 
times ulcerated. Vomiting is a common symptom, commencing in some 
cases early, but in others not till the diarrhoea has continued a few days. 
Sometimes it appears to be a symptom of indigestion produced by the 
imperfectly digested or fermented and acid food in the stomach. Occur- 
ring at a late period it may have a cerebral origin from commencing spu- 
rious hydrocephalus, or it may be due to impaired function of the kidneys 
in consequence of which urea is retained in the system, and is excreted in 
the stomach. The matter vomited, when the vomiting is due to irritat- 
ing substances in the stomach, has a sour odor, and produces a decidedly 
acid reaction with the appropriate tests. It contains coagulated casein, 
and undigested particles of whatever food has been given. I found from 
observations made in 1863 and 1864, in reference to the summer intesti- 
nal catarrh of infants, that vomiting commenced in less than one week 
after the diarrhoea, in a majority of the cases which I observed in those 
years. 

The stools sometimes continue during the whole course of the malady 
of nearly the same character as at first. In other patients they vary in 
color and consistence at different periods, this change being due partly to 
the nature of the food. In the same case they may be brown and offen- 
sive at one time, green like mashed vegetables at another, and again they 
may contain masses of a putty-like appearance, the partly digested casein. 
They may consist largely of mucus, with or without blood, such stools 
indicating a predominance of inflammation in the colon. The malady, 
which Barrier designated mucous diarrhoea, is chiefly a colitis. The 
stools are sometimes yellow when passed, but become green by exposure 
to the air, or from chemical reaction due to admixture with the urine. 

The microscopic character of the stools in entero-colitis is interesting. 
Aside from undigested casein, I have found unaltered fibres of meat, crys- 
talline formations, epithelial cells, single or arranged regularly in clusters, 
as if detached from the villi, mucus, sometimes blood, and, in one case, 
an appearance resembling three or four crypts of Lieberkuhn united. If 
the stools are green, colored masses of various sizes, but mostly small, 
are also seen with the microscope. The microscopic elements, then, are 
the excrementitious substances, particles of undigested food, inflammatory 



SYMPTOMS. 701 

products, and epithelial cells or fragments of the mucous membrane, 
thrown off by the inflammatory process. 

The pulse in entero-colitis is accelerated. There is, frequently, in- 
creased heat of surface in the commencement, but, as the disease con- 
tinues, the vital powers soon become reduced, and the surface is either of 
the natural temperature or cool. As death approaches, the pulse grad- 
ually becomes more frequent and feeble, and the extremities, sometimes 
for hours before life is extinct, have a cadaverous pallor and coldness. 
The skin, in intestinal inflammation, is generally dry, and the urinary 
secretion diminished. In severer forms of the disease, attended by fre- 
quent evacuations from the bowels, the infant does not pass its urine 
oftener than once or twice daily. The imperfect action of the skin and 
kidneys is a noteworthy feature of the inflammation. The advanced 
stages of entero-colitis are apt to be complicated by two cutaneous affec- 
tions, namely, erythema between the thighs, probably produced by the 
acid and irritating character of the stools, and boils upon the forehead 
and scalp. The latter sometimes extend down to the pericranium, and 
leave permanent depressed cicatrices. The external irritation caused by 
the furuncular affection has often seemed to me conservative, as it occurs 
at the time when there is danger from passive congestion of the brain and 
serous effusion. When entero-colitis is protracted, and the patient is 
much reduced, remaining constantly in the recumbent position, except 
when held in the arms of the mother or nurse, another symptom fre. 
quently arises, namely, a dry cough, which continues till the close of life, 
if the case be fatal, and subsides slowly if the disease terminate favor- 
ably. The complication which gives rise to this symptom will be consid- 
ered hereafter. As death approaches, the infant sometimes becomes 
more fretful ; it turns peevishly from playthings, rolls its head, or the 
head has an unsteady movement ; and often the stomach becomes more 
irritable. The experienced physician rightly interprets these symptoms 
as the forerunner of cerebral accidents. In other cases there is too great 
prostration even for the exhibition of restlessness, and the patient lies 
quiet. As death approaches the infant becomes drowsy. The limbs are 
cool. It refuses to nurse, or, if spoon-fed, takes nutriment apparently 
without relish. The pupils are contracted, and insensible to light. The 
eyes are bleared, and a puriform secretion occasionally collects between 
the lids. The stools are less frequent, and the vomiting, if previously 
present, ceases. Death occurs quietly. 

Sometimes, however, convulsive movements precede death, generally 
slight, as of one arm, or of the limbs on one side. Uraemia may be the 
immediate cause of death in certain cases. 

In chronic entero-colitis there is extreme emaciation for a considerable 
time before death. The skin of the extremities lies in wrinkles ; the 



702 INTESTINAL CATARRH OF INFANCY. 

joints, from contrast, appear enlarged, and the ringers and toes elongated ; 
the angular projections of the bones are prominent. The hollowness of 
the cheeks and eyes causes the infant to appear much older than it really 
is. Death occurs in a state of extreme exhaustion. 

The above description applies to infantile entero-colitis, as it so fre- 
quently occurs in the cities. It is sometimes much more violent, attended 
by much greater febrile reaction, and is more speedily fatal. Especially 
is this the case when it is due to the impression of cold ; such cases are 
not infrequent in the winter months, in the country as well as city. 

Instead of the mild and gradual commencement which I have described, 
infantile entero-colitis may be produced by violent symptoms — a true 
cholera morbus in which vomiting and purging, more or less severe, pre- 
cede the inflammation. Among my records are cases which commenced 
in the summer season from eating gooseberries, currants, cherries, and 
cheese ; the choleraic symptoms produced by these indigestible substances 
ending in protracted inflammation. 

Anatomical Characters. — Billard says : " In eighty cases of inflam- 
mation of the intestines that I examined with great care, there were thirty 
of entero-colitis, thirty-six of enteritis, and fourteen of colitis." M. 
Legendre, in twenty-eight cases of diarrhoea, found colitis alone in nine, 
and in the cases in which enteritis occurred, colitis was also present. 
Eilliet and Barthez state that in certain rare instances almost the entire 
digestive tube is affected ; that in exceptional cases the principal lesion is 
found in the smal] intestines, while, on the other hand, the large intestine 
is the part of the alimentary canal which is most frequently and intensely 
inflamed. Billard describes four kinds of intestinal phlegmasia : first, 
erythematic ; second, with altered secretion ; third, follicular ; fourth, 
with disorganization of tissue. In some of the best works on diseases of 
children, published subsequently to that of Billard, different forms of in-> 
flammation are described, according to the presence or absence of certain 
anatomical changes, as ulceration or softening. Practically little is gained 
by such a division of the general disease, and the lesions which are made 
the basis of the division are often merely the result of severe and pro- 
tracted, simple or catarrhal, inflammation. I have records of the post- 
mortem appearances in eighty-two cases of intestinal inflammation in the 
infant. Eleven of these occurred in private or dispensary practice ; about 
fifty in the Nursery and Child's Hospital, and the remainder in the Infant 
Asylum. Since preserving these records, I have witnessed a larger num- 
ber of post-mortem examinations of infants who died of this disease, chiefly 
in the institutions, and the lesions corresponded in general with those 
already observed. The question may properly be asked, Can inflamma- 
tory hypersernia of the intestinal mucous membrane be distinguished from 
simple congestion if there be no ulceration and no appreciable thickening 
of the intestine ? This is sometimes difficult, and it is possible that occa- 



ANATOMICAL CHARACTERS. 703 

sionally I have recorded as inflammatory what was simply a congestive 
lesion, but I do not think that I have incorporated a sufficient number of 
such cases to vitiate the statistics. In a large proportion of the autopsies 
there was manifest thickening of the intestinal mucous membrane or other 
unequivocal evidence of inflammation. The following is an analysis of 
the eighty-two cases : 

The upper part of the small intestine, embracing the duodenum and 
jejunum, was found inflamed in twelve cases. It was free from inflamma- 
tion, and of a pale color, in fifty-one cases. The ileum was inflamed in 
forty-nine cases, and the caecal portion, including the ileo-caecal valve, 
was the part in which the inflammation was uniformly most intense, and to 
which it was often confined. In sixteen cases there was no ileitis, and in 
thirteen no enteritis whatever. Therefore, the ileum was inflamed in all 
but three of the cases of enteritis, in which the records give the exact 
location of the disease. In fourteen cases vascularity was observed in 
streaks or in patches, or simple arborescence in some part of the small in- 
testines, the records not stating its exact location. 

In most cases the inflamed mucous membrane was perceptibly thickened. 
Occasionally, especially if the vascularity were slight, the thickening was 
scarcely appreciable. In one case there was so much thickening of the 
ileum next to the ileo-caecal valve that the mucous coat appeared as if 
closely studded with small warts. Ulcers of small size were found in the 
mucous membrane of the small intestines in five cases. These ulcers in 
one case were in the jejunum, in two in the ileum, and in two in both 
these divisions of the intestine. They were for the most part quite super- 
ficial, and circular or oval. 

It is seen from the above records that the portion of the small intestine 
most frequently inflamed was the ileum. The inflammation usually affected 
the ileo-cascal valve, and extended from it to a greater or less extent along 
the small intestine. In general, when inflammatory patches were found 
in different parts of the small intestine, those in the ileum nearest the 
ileo-caecal valve presented the greatest vascularity and thickening. Bil- 
lard noticed in his cases the frequency and intensity of the inflammation 
in the terminal portion of the ileum, and the consequent thickening of the 
ileo-caecal valve, and conjectured that the vomiting so common and obsti- 
nate in enteritis might be due to obstruction at the ileo-caecal orifice in 
consequence of this thickening. I have often seen the orifice reduced to 
a very small size from the hyperaemia and thickening of the valve, but 
have not seen any accumulation above it or other evidence of obstruction. 

The inflamed mucous membrane was softened in greater or less degree 
according to the intensity of the inflammation. Sometimes the vessels of 
the submucous connective tissue were injected, and this tissue infiltrated. 
The softening of the mucous coat, and the firmness of its attachment to 
the parts underneath, varied considerably in different specimens. I was 



704 INTESTINAL CATARRH OF INFANCY. 

able, in cases in which there was softening, to detach readily the mucous 
coat with the nail or back of the scalpel, within so short a period after 
death that it was evident that the change of consistence could not have 
been cadaveric. 

The infants in whom the duodenum and jejunum presented the inflam- 
matory lesions were, with few exceptions, under the age of three months, 
and in many of these cases there was hypersemia of the gastric mucous 
membrane, and in some also stomatitis. 

In all the cases except one, namely, in eighty-one, lesions were present, in- 
dicating inflammation of the mucous membrane of the colon. In thirty- 
nine, the catarrh extended over nearly or quite the whole extent of this 
portion of the intestine ; in fourteen, it was confined to the descending 
portion entirely, or almost entirely ; in twenty-eight cases, the records 
state that colitis was present, but its exact location was not mentioned. 
In eighteen of the examinations, the mucous membrane of the colon was 
found ulcerated. According to these statistics, therefore, colitis is present 
in nearly every case of intestinal inflammation in infancy, and in a large 
proportion of cases also ileitis. The portion of the colon which is most 
frequently inflamed is that in and immediately above the sigmoid flexure. 
If the colitis affect other portions also, it is, nevertheless in this part that 
we find the most marked inflammatory lesions. 

The solitary glands, both of the large and small intestines, and Peyer's 
patches, are involved in most cases of intestinal catarrh. Even in non-in- 
flammatory diarrhoea they become tumefied, so as to be distinctly visible 
and somewhat elevated. In entero-colitis, as we have already seen, they 
present different appearances, according to the degree and duration of the 
inflammation. In recent cases, and in parts of the intestine where the in- 
flammatory action has been mild, there is often no perceptible change of 
these glands except slight enlargement with vascularity. This enlarge- 
ment is most apparent if the intestine be viewed by transmitted light, 
when not only the glands are seen to be swollen, but their central dark 
points are quite distinct. If a higher grade of inflammation, or inflamma- 
tion more protracted have occurred, the volume of the solitary follicles is so 
increased that they rise above the common level and present a papillary 
appearance. Peyer's patches are in a corresponding degree thickened. 

The enlargement of these glands is due to hyperplasia, namely, an 
augmentation in the number of the elementary cells. The ulceration in 
the cases which I have examined appeared to be primarily and chiefly fol- 
licular. While some of the solitary glands in a specimen were found sim- 
ply tumefied, others were slightly ulcerated, and others still nearly or 
quite destroyed. The ulcers were usually from one to three lines in 
diameter, circular or oval, with edges a little raised, and red. They 
resembled in appearance the ulcers in follicular stomatitis. In one or two 
instances I have seen small coagula of blood in the ulcers, and I have also 



ANATOMICAL CHARACTERS. 705 

seen ulcers which have evidently been larger, having partially healed. 
The principal seat of the ulcers was in the descending colon. They were 
either found in this portion of the intestine only, or, if occurring else- 
where, they were here most abundant. 

Those in whom I have found ulcers have been ordinarily over the age 
of six months, which is the time when there is greatest development and 
activity of the glandular apparatus. In none of the cases observed by me 
were Peyer's patches ulcerated, though generally tumefied. 

In cases in which the caput coli was inflamed, I have sometimes found 
the mucous membrane of the appendix vermiformis also injected and 
thickened. In one case only was there a pseudo-membrane upon the in- 
flamed surface. This was in the descending colon, and it was thin like a 
film. The rectum presented no inflammatory or other lesions, or but 
slight lesions in comparison with those in the colon. Often, when there 
was almost general colitis, the rectum was found of a pale color, or but 
slightly vascular. This may explain the infrequent occurrence of tenes- 
mus in infantile entero-colitis. The amount of mucus secreted from the 
intestinal surface in this disease is considerably in excess of the normal 
quantity. It often forms a layer upon the mucous membrane of the in- 
testines, and appears in the stools, mixed with epithelial cells and some- 
times with blood or pus. If the quantity of mucus appearing in the 
stools be considerable, this form of intestinal catarrh has sometimes been 
designated mucous diarrhoea, or mucous disease ; but there does not seem 
to me sufficient reason, either anatomical or clinical, for considering it a 
distinct malady. 

The mesenteric glands are ordinarily enlarged, unless in very young 
infants. They are frequently found as large as a large pea, or even larger, 
and of a light color, from the anaemic state of the infant. In exceptional 
instances certain of them are found to have undergone cheesy degenera- 
tion. The enlargement of these glands, like that of the solitary follicles 
and Peyer's patches, occurs from hyperplasia. The condition of the 
stomach was recorded in sixty-nine cases. In forty-two it was healthy ; 
in seventeen red, apparently inflamed ; in seven of a pink color ; in three 
it contained ulcers which were probably cadaveric. The usual healthy 
condition of the stomach is a noteworthy fact, taken in connection with 
the frequent vomiting, in intestinal catarrh. I have stated elsewhere that 
stomatitis is also a common complication in protracted and grave cases, 
accompanied by sponginess of the gums, which bleed if pressed or 
rubbed. The buccal surface in these cases is more vascular than natural, 
and, if the vital powers are much reduced, superficial ulceration is not 
infrequent, especially of the gums. In infants under the age of three or 
four months, oesophagitis is also a common accompaniment of entero- 
colitis. 

Thrush, though a frequent complication under the age of three or four 
45 



706 



INTESTINAL CATARRH OF INFANCY 



months, is rare in older infants. Thrush, in infants over the age of 
eight or ten months, occurring in connection with intestinal inflammation, 
is an unfavorable prognostic sign, indicating a gravity of the intestinal 
disease which commonly eventuates in death. 

An opinion exists in the profession that the liver is in fault in this 
disease, especially in that form of it which I have described as a sum- 
mer epidemic of the cities. This opinion is, probably, less prevalent than 
formerly, but is still held by many, and it influences the choice of thera- 
peutic agents. 

I have notes of the appearance and state of the liver in thirty -two fatal 
cases of the epidemic entero-colitis of the summer season. Nothing could 
be seen in these examinations that indicated any disturbance in the func- 
tion of this organ. The size of the liver was in some cases very different 
in those of about the same age, but probably there was no greater differ- 
ence than usually obtains among glandular organs within the limits of 
health. The following table gives the weight of the liver in twenty cases 
in which the weight of this organ and the age of the patient are recorded : 



Age. 
4 weeks, 
2 months. 
2 
4 
5 
5 
7 
7 
7 
9 







Age. 


5 ounces. 


10 months, 


31 " 


13 


(i 


31 " 


14 


" 


5 " 


15 


" 


6£ " 


15 


" 


9 " 


15 


K 


4i " 


16 


" 


6 " 


19 


a 


6} « 


20 


" 


8 " 


23 


" 



6f ounces. 

6 

9 

6 

7$ « 

n " 

6 

41 " 
9i " 
15 



I do not have access to tables giving the weight of the healthy liver at 
different ages, but in none of the above examinations did the size or the 
weight seem to me to be above the healthy standard, except in one, in 
which this organ was quite fatty. But in this case the degeneration and 
enlargement of the liver were doubtless due to tuberculosis. 

In most of the cases the liver was examined microscopically, and the 
only fact worthy of note observed was its variable amount of fatty mat- 
ter. Sometimes this was in excess, sometimes in moderate quantity or 
rather deficient, and sometimes in greater amount in one portion of the 
organ than in another. 

The prevalent belief, then, that the liver is greatly affected in the 
summer epidemic of entero-colitis, receives no corroboration from the in- 
spection of this organ. The only pathological state (if it be such) ob- 
served in it relates to the amount of oily matter, and this obviously 
requires no special treatment. 

The cutaneous affections complicating entero-colitis have already been 
alluded to. 



ANATOMICAL CHARACTERS. 707 

Frequently at post-mortem examinations of infants who have died of 
intestinal catarrh, intussusceptions are found in the small intestines. 
These probably in general occur at the moment of, or not long before, 
death, as they are small and readily reduced, but I have in a few instances 
found intussusceptions which sustained the weight of two feet or more of 
intestine without being reduced, and which, from being in their interior 
more vascular than the contiguous membrane either above or below, prob- 
ably occurred some hours, possibly days, before death, but, being suffi- 
ciently pervious to allow the food to pass, symptoms of obstruction were 
absent. 

It has been said, in speaking of the symptoms, that a cough is common 
in protracted entero-colitis when the vital powers are greatly reduced, and 
the circulation is feeble. From the great emaciation and the character of 
the cough, the physician as well as friends is very apt to suspect the pres- 
ence of tubercles. But tuberculosis is quite exceptional in these cases. I 
have, as stated above, records of eighty -two post-mortem examinations of 
infants who died of entero-colitis in the summer months, and tubercles 
were found in only one case. The cough was due to solidification of the 
posterior and dependent portion of one or both lungs. The mode in 
which this solidification of the lung (hypostatic pneumonia) occurs and 
its character are treated of in our remarks on disease of the respiratory 
organs. 

In the cases of entero-colitis which were complicated with this state of 
the lungs, I have not usually found enough of the lung-tissue involved to 
make any perceptible difference in the sound on percussion. Its extent 
of solidification was sometimes not more than two or three lines, and fre- 
quently not more than a quarter to half an inch in an antero-posterior 
direction, although it embraced nearly or quite the entire posterior sur- 
face of the organ. 

The state of the brain in the entero-colitis of infancy is interesting to 
the pathologist. When the disease is protracted, this organ wastes like 
the body and limbs. In the young infant, in whom the cranial bones are 
still ununited, the occipital and sometimes the frontal become depressed 
in proportion to the loss of brain-substance, so that the cranium is quite 
uneven. In older children with the cranial bones consolidated, serous 
effusion occurs according to the degree of waste, thus preserving the size 
of the encephalon. The effusion is chiefly external to the brain, extend- 
ing on each side over the convolutions from the base to the vertex. The 
quantity of serum varies from one or two drachms to an ounce, or even 
more. The serous effusion is associated with passive congestion of the 
cerebral vessels and cranial sinuses, and this pathological state when suffi- 
cient to produce symptoms, occurs in the common form of spurious hy- 
drocephalus. 

The following is a common example : 



708 INTESTINAL CATARRH OF INFANCY. 

In December, 1877, my attention was called to an infant, aged seven 
months, just admitted into the New York Foundling Asylum, with sus- 
pected brain disease. Its previous history had not been ascertained ; its 
pupils reacted feebly by light, and its head constantly rotated from side 
to side. The diagnosis was easy from the symptoms, for its wasted state, 
and sunken eyes, without any marked pulmonary symptoms, indicated 
protracted intestinal catarrh, and the depressed anterior fontanelle, showed 
that the brain disease could not be an inflammation either meningeal or 
cerebral. It was obvious that the anatomical state of the brain, which we 
are now considering, was present. At the autopsy on the following day, 
the lesions of severe protracted intestinal catarrh were found. The large 
intestine especially was thickened, and its mucous surface rough and un- 
even from proliferation of the mucous membrane, or sub-mucosa, which 
had evidently been going on for a considerable time. The portions of the 
surface which were roughened by this proliferation presented a dusky-red 
color. On opening the cranial cavity about one ounce of serum escaped, 
which had been effused between the superior surface of the brain and the 
meninges. The anterior portion of the brain, which was uppermost in 
the position in which the child bad been in the crib, appeared normal, 
but the veins and capillaries in the posterior or depending portion were 
engorged with dark blood. The base of the brain did not present any 
inflammatory lesion. The cranial sinuses were also distended with dark 
blood and clots ; a long white clot was drawn out from the longitudinal 
sinus, being, from its color and firmness, in all probability, ante-mortem ; 
the presence of which, whatever the condition otherwise, obviously ren- 
dered recovery impossible. 

Diagnosis. — Persistent diarrhoea, with elevation of temperature, indi- 
cates intestinal catarrh. Abdominal tenderness, which is so important a 
diagnostic symptom in the adult, is generally absent in the infant, or, if 
present, is not easily ascertained. It is more difficult to determine, from 
the symptoms, what part of the intestinal tract is chiefly involved in the 
catarrh, though it may be assumed that it is the colon, and the lower part 
of the ileum if the patient be under the age of eighteen months. The 
presence of mucus, or of mucus tinged with blood, in the stools, shows 
predominance of colitis. 

Prognosis. — Though intestinal inflammation is one of the most fatal 
infantile maladies, still, by proper hygienic measures and a judicious selec- 
tion and use of medicines, a large proportion of those affected may be 
saved. This inflammation and most of its complications are of such a 
nature that we may have reasonable hope that the infant will recover if 
suitable measures are employed sufficiently early. Many do recover from 
a state of emaciation and feebleness which, occurring in any other patho- 
logical state, would be almost necessarily fatal. The most unfavorable 
symptoms in this disease, except those due to extreme prostration or col- 
lapse, arise from the state of the brain. Rolling the head, squinting, fee- 
ble action of the pupils, spasmodic or irregular movements of the limbs, 
indicate the near approach of death. There are many facts which should 
be taken into consideration in making a prognosis. The age of the in- 



TREATMENT. 709 

fant, the time in the year, the surroundings, especially in reference to the 
impurity of the atmosphere, are to be considered, as well as the present 
state of the patient. 

Intestinal inflammation of infancy might, in many instances, be pre- 
vented by judicious measures. Especially is it preventable in those cases 
in which the exciting cause is dietetic. The reader is referred to the 
chapters on weaning and artificial feeding, for facts in reference to this 
matter. Unfortunately, however, the physician in many instances is not 
consulted in regard to the alimentation of the infant, or the time and 
manner of weaning, or other important matters of regimen, until diarrhoea, 
inflammatory or non-inflammatory, is established ; his purpose is then 
not to prevent, but to cure. 

Treatment. Regimenal Measures. — The infant with intestinal catarrh 
is thirsty, and is, therefore, apt to take more nutriment, in the liquid 
form, than it requires. If nursing it craves the breast, or if weaned craves 
the bottle at short intervals, but no more nutriment should be allowed 
than is required for the sustenance of the patient, since an amount of food 
which cannot be fully digested undergoes fermentative changes and be- 
comes an irritant to the intestines. The infant should, therefore, take its 
food in proper quantity and at proper intervals, and if it be thirsty, it 
should, take a little gum water or light barley water, or a little cold water, 
in the intervals. But exhaustion should be guarded against, and while 
the diet should be bland and unirritating, it should be nutritious. 

As one of the chief causes of intestinal catarrh, when not produced by 
exposure to cold, is the use of indigestible and therefore irritating food, it 
is obviously of the utmost importance that the food should be of suitable 
nature, properly prepared, and given in proper quantity. This remark is 
especially applicable to the catarrh of the summer months, the cause of 
which is largely dietetic. To infants under the age of one year, and even 
under that of fifteen months, no food is so suitable as the breast- milk, 
and one affected with the " summer complaint, " and remaining in the city, 
will not in general do well unless it obtain the milk either of its mother 
or a wet-nurse. Many are the instances, every summer, in New York 
City, in which the diarrhoea continues in spite of all other measures, 
hygienic and medicinal, till a wet-nurse is employed, when in consequence 
of the changed diet there is rapid and complete restoration to health from 
a state of emaciation and weakness. 

But if the mother's milk fail or become unsuitable on account of ill- 
health or pregnancy, and in consequence of family circumstances a wet- 
nurse cannot be employed, the important and difficult duty devolves upon 
the physician of deciding what shall be the diet. The shops contain sev- 
eral kinds of infants' food, most of which are proprietary, and the mode 
in which they are prepared and the materials employed are kept secret. 
A physician actuated by the proper spirit will not recommend a food 



710 INTESTINAL CATARRH OF INFANCY. 

whose exact composition is unknown, or the materials employed in the 
making of which are not fully stated, especially if food can be conven- 
iently prepared by the family which is equally good. 

As the breast-milk is the best possible food in cases of infantile diar- 
rhoea, in patients under the age of twelve or even eighteen months, the 
belief is reasonable that the best substitute for it is such food as most 
nearly resembles it, and cow's milk or goat's milk, when fresh and of 
good quality, more closely approximates to it in its ingredients and 
chemical character than any of the artificial preparations. Besides a close 
observation through many summers has convinced me that bottle-fed 
infants, as a rule, do better if a part at least of their food be the milk of 
one of these animals, prepared according to the directions in the chapter 
relating to artificial feeding. Great care is requisite that the food be of 
good quality, properly diluted, and without the least appreciable ferment- 
ative change. But to obtain and preserve milk, in a state suitable for 
use by night and day, is a real difficulty in a large city whose milk supply 
is received only once in twenty-four hours, and from remote dairies. 
Condensed milk has the advantage of more easy preservation, and accord- 
ingly it is largely employed. 

Of the infants' food furnished by the shops, some are used with milk, 
as the imperial granum, and Ridge's and others with water ouly, as Nestle 's, 
and the Anglo-Swiss food of Cham, Switzerland, recently introduced. 
But no one of these is, in my opinion, sufficiently nutritive for prolonged 
use, so that milk or some other nutriment is required in addition for 
the proper nutrition of the infant. Infants often do well for a time on 
Ridge's food and milk, the imperial granum and milk, Nestle's food 
alternating with milk, or the Anglo-Swiss food alternating with milk, 
but in most instances, sooner or later, before the hot weather is over, 
diarrhoea occurs, necessitating some change of diet. 

The one food in the shops which, on account of its excellence, merits 
most the confidence of the profession is Liebig's. One of the last and 
the crowning work in the life of the distinguished chemist was the prep- 
aration of this food. Learning from the physiologist that young infants 
could digest only a small amount of starch, he prepared a food in which 
the starch is converted into glucose, and is thus made assimilable for in- 
fants only a few weeks old ; and influenced solely by the desire to dimin- 
ish sickness and save human life, he published to the world each step of 
the process. Liebig's food is now prepared by three competent parties, 
Ilawley, Horlich, and Mellen. Consisting largely of glucose or grape 
sugar, if given in considerable quantity, without admixture with other 
food, I have found it too laxative for use in diarrhoeal maladies, for all 
the sugars are more or less laxative, but if mixed with the proper propor- 
tion of milk so as to sweeten it slightly, it is probably the best food for 
infants under the age of three or four months. For those above this age, 



TREATMENT. 711 

who can digest starch, Liebig's food mixed with whatever farinaceous 
substance is employed, in the proportion of one to three, and used with 
milk, agrees with a large proportion of infants affected with diarrhoea. 
With this glucose food, which is a nutriment, it is not necessary to use 
cane-sugar, which is decidedly laxative, to sweeten the food in the diarrhoea! 
maladies. 

Of the farinaceous foods, barley flour has probably been the most used 
in New York in recent years. But in the treatment of the summer diar- 
rhoea I am in the habit of employing wheat flour of the best quality, pre- 
pared by long boiling. Two pounds of this flour are pressed dry in a 
bag, and this is boiled twelve hours over a brisk fire and in water suffi- 
cient to cover it fully. When removed from the bag it has the appear- 
ance of chalk, and should be grated when needed for use. Witthaus, in his 
recent treatise on medical chemistry, says of starch : " When subjected 
to dry heat the granules of starch swell and burst ; at 200° it is converted 
into dextrin" (page 311), and processes which change starch into dex- 
trine if continued are apt to produce more or less glucose. Whatever be 
the exact change effected, wheat flour thus prepared will be found very 
useful in all infantile diarrhoeas. A gruel should be made of the flour, 
and milk afterward added. Milk should only be boiled for a few min- 
utes. Boiling does not apparently render it more constipating, but it 
prevents early souring, which is a matter of importance, when milk is 
brought from a distance and only once each day. It is well to test the milk 
by litmus-paper, and if it show more than a trace of acid it should be re- 
jected. In one of the New York institutions a little lime-water or other 
alkali is frequently added to the milk on hot days to insure against acid- 
ity. Cases, however, occur, and not infrequently, during the heated term, 
in which it is necessary to discontinue entirely the use of milk. In a 
recent case in my practice, cow's milk was so imperfectly digested and so 
quickly passed the bowels that the microscope showed the presence of 
even the oil globules in the stools. In such cases I have obtained the 
best results by preparing a gruel with the flour, and adding to the quan- 
tity used at each feeding, after it became cool, the white or albumen of 
half a fresh egg. With this change in the diet, the number of stools has 
frequently diminished at once. Beef, mutton, or chicken tea should 
not be given, as they are too laxative, but the expressed juice of beef and 
scraped raw beef , except as it involves danger of producing the tape- worm, 
are useful additions to the diet. 

But one chief cause of the great summer epidemic of intestinal catarrh, 
in the cities, we have seen to be atmospheric. This requires attention on 
the part of the practitioner, to a different matter in the hygienic manage- 
ment of these cases, namely, the state of the air which the infant breathes, 
in cool months the atmosphere is more pure than in the summer months, 
as it contains less of those noxious gases which arise from decaying animal 
and vegetable substances. In those months, then, in which the weather 



712 INTESTINAL CATARRH OF INFANCY. 

is such that there is no decomposition of organic matter, the atmospheric 
cause of entero-colitis is less operative, and less is gained for the patient 
by change of locality. But in the summer season one of the most impor- 
tant conditions of successful treatment of this and the other diarrhoeal mal- 
adies of infancy is the. removal of patients from an impure to a pure 
atmosphere. Physicians of experience all agree in the choice of salubri- 
ous localities, containing a sparse population. Many are the instances 
every summer in this city of infants removed to the country with intestinal 
inflammation, with features haggard and shrunken, with limbs shrivelled, 
and skin lying in folds, too weak to raise or at least hold their heads 
from the pillow, vomiting nearly all the nutriment taken, with stools fre- 
quent and thin, resulting in great measure from molecular disintegration 
of the tissues, presenting indeed an appearance seldom seen in any other 
disease except in the last stages of phthisis, and returning in late autumn, 
with the cheerfulness, vigor, and rotundity of health. The localities 
usually preferred by the physicians of this city are the elevated portions 
of New Jersey and Eastern Pennsylvania, the Highlands of the Hudson, 
the central and northern parts of New York State, and Northern New 
England. Taken to a salubrious locality, the infant will soon begin to 
improve after it has recovered from the fatigue of travelling, unless the 
case be exceptionally obstinate. 

Sometimes parents, not noticing the immediate improvement which 
they had been led to expect, return to the city without giving the country 
fair trial, and the life of the infant is almost necessarily sacrificed. Ee- 
turned to the foul air of the city while the weather is still warm, it sinks 
rapidly from an aggravation of the malady. Some authors recom- 
mend, if the infant do not improve where it is taken, that it should be 
conveyed to another locality. This is good advice, provided that the 
selection be made of a place elevated, and having a sparse population. 
The infant, although it has recovered, should not be brought back while 
the weather is still warm. One attack of the disease does not diminish 
but increases the liability to a second seizure. 

If the situation of the family be such that it is not practicable to take 
the infant to the country, and such cases are frequent among the poor, it. 
should be kept much of the time in the open air ; it is a common prac- 
tice in this city to take such patients in the daytime to the seashore, or 
upon ferry-boats. Dr. E. H. Parker says : " Many of my patients are 
sent to the ferries to cross them, so that the cool, fresh sea-breeze may 
fan them, and it acts sometimes like magic, to raise their drooping 
heads. ' ' I have not observed such marked benefit in these cases from the 
sea-breeze as from the air of elevated rural localities, which can generally 
be found in the vicinity of cities, and are easily accessible. 

In New York great benefit has resulted from the floating hospital which 
every second day during the heated term carries a thousand sick children 



TREATMENT. 713 

from the stifling air of the tenement-houses down the bay and out to the 
fresh air of the ocean. 

Medicinal Treatment. — Sometimes it is proper to commence treatment 
bv the employment of a gentle purgative, particularly when the disease 
commences abruptly from a state of previous good health. It is then fre- 
quently caused by exposure to cold, or more rarely by some indigestible 
and highly irritating substance in the intestines. In such patients there 
is often a full habit. The pulse is strong and quick, the heat of surface 
great, the face perhaps flushed, the stools sometimes slimy and bloody, 
sometimes green or brown. It is proper and often serviceable, 'when 
there is this commencement of the affection, to give a single dose of cas- 
tor oil or syrup of rhubarb. Any indigestible substance, if present, is 
removed from the intestine, and opiates or other remedies designed to 
control the disease may then be more successfully employed. Such cases 
occur in the winter not less than in the summer, and in all localities, rural 
as well as in the city. But the summer epidemics of intestinal inflamma- 
tion in the cities do not in general require such preliminary treatment. 
Diarrhoea, moderate, perhaps, has already continued for a time when the 
physician is called, and no irritating substance remains except the acid, 
which is abundantly generated in the intestine in this disease, and which 
we have the means of removing without purgation. Preliminary treat- 
ment having been employed or not, according to the nature of the attack 
and condition of the patient, remedies calculated to arrest the inflamma- 
tion should then be prescribed. 

The same general plan of medicinal treatment holds good for the intes- 
tinal catarrh of infants which has been found efficacious for that of 
adults. But the causes of this catarrh are, as we have seen, in some re- 
spects different in infancy from those operative in other periods of life, 
so as to require some variation in the treatment. The acid fermentation 
occurring in the stomach, which is very common, especially in the 
catarrh of the summer season, requires the use of antacids. If by the ap- 
pearance of the stools, or the substance ejected from the stomach, or by 
the usual test with litmus paper, the presence of acid in an irritating 
quantity be ascertained or suspected, lime-water or a little bicarbonate of 
sodium should be added to the food. The creta preparata of the pharma- 
copoeia, or, which is more convenient, the mistura cretae, administered every 
two hours, is an useful antacid for this condition. By the alkali alone, aided 
by the judicious use of stimulants, the disease is sometimes arrested ; but, 
unless circumstances are favorable, and the case be mild, other medicines are 
required. The physicians should see that the chalk is finely triturated. 

Opium is used by most practitioners in the treatment of this malady. 
Either as a main remedy or adjuvant, it is employed, and properly, in 
nearly all severe cases. For a young infant paregoric is an eligible prepa- 
ration of opium. For the age of one month, the dose is three to five 



714 INTESTINAL CATARRH OF INFANCY. 

drops ; for the age of six months, ten to twelve drops, repeated in three 
hours or a longer time, according to the state of the patient. After the 
age of six months the stronger preparations of opium are more frequently 
used. At the age of one year the liq. opii compositus or tinctura opii 
deodorat. may be given in doses of one drop. Dover's powder is also a 
useful medicine in this disease, given in doses of three-fourths of a grain 
to an infant one year old. 

Opium is, however, in general best given in mixtures which will be 
mentioned hereafter. It quiets the action of the bowels, and diminishes 
the number of evacuations. It is contraindicated or should be used with 
caution if cerebral symptoms be present. Sometimes in the commence- 
ment of the disease, if there be much febrile reaction, the patient may be 
drowsy and in danger of convulsions. Then opiates should be given cau- 
tiously. Also in the advanced stages of this disease, when, perhaps, 
there is more or less serous effusion in the cranial cavity, opium should be 
cautiously prescribed, as it might tend to produce that fatal stupor, in 
which unfavorable cases are apt to terminate. 

Astringents have long been used as an adjuvant to the opiate, but the 
medicine, which, employed in combination with opium, is the most effi- 
cient in controlling infantile entero-colitis, is the subnitrate of bismuth. 
While it aids strongly in checking the diarrhoea, it is an efficient anti- 
emetic and antiseptic. It should be prescribed in doses of ten or twelve 
grains for an infant of twelve months, and larger doses produce no ill 
effect, for its action seems to be almost entirely local, and soothing upon 
the intestinal surface. It undergoes a chemical change in the stomach, 
becoming black, being probably converted into the bismuth sulphide, 
and it produces dark stools. An observing physician has informed me 
that he has sometimes observed a peculiar faint odor, somewhat like 
that of garlic in the breath of those who are taking the bismuth in fre- 
quent large doses. I have since observed this in two instances. It is 
probably due to some impurity, and not the result of absorption of the 
bismuth. In those cases in which the symptoms are chiefly due to the 
colitis, and the stools contain blood with a large proportion of mucus, it 
has been customary to prescribe laudanum or other form of opium with 
castor oil. I now prefer, however, the bismuth and opium in the treat- 
ment of cases which are more decidedly dysenteric, as well as for cases of 
the usual form of intestinal catarrh. 

The following formulae are employed with the best results in the insti- 
tutions of New York, with which I have an official connection, the dose 
being for an infant of one year : 

. Tine, opii deodorat., gtt. xvj ; 
Bismuth, subnitrat., 3ij; 
Syr. simplic. , § ss ; 
Mistur. cretae, f iss. Misce. 
Shake bottle. Give one teaspoonful every two to four hours. 



TREATMENT. 715 

B. Tine, opii deodorat., gtt. xvj ; 
Bismuth, subnitrat. , 3 ij , 
Syr. simplic, § ss ; 
Syr. cinnamomi, §iss. 
Shake bottle. Give one teaspoonful from two to four hours. 

B. Bismuth, subnitrat, 3 ij ; 

Pulv. cret. comp. c. opio, 3 ss. Misce. 
Divid. in chart. No. x. Dose, one powder every three hours. 

B. Bismuth, subnitrat., 3 i j ; 

Pulv. ipecac, comp., gr. ix. Misce. 
Divid. in chart. No. xii. Dose, one powder every three hours. 

An infant of six months can take half the dose, and one of three or 
four months one fourth or one third the dose of either of the above mix- 
tures. 

Enernata. — These are of great service in many cases of intestinal in- 
flammation. At any stage of the disease, when the stomach is irritable 
and medicines are not retained, they may be advantageously employed. 
Laudanum especially is often given in this way to the infant with great 
benefit. It may be prescribed mixed with a little starch-water, and the 
best instrument for administering it is a small glass or gutta-percha 
syringe, the nurse retaining the enema for a time by means of a com- 
press. Beck, in his Infant Therapeutics, advises to give by injection 
twice as much of the opiate as would be administered by the mouth. A 
somewhat larger proportion may, however, be safely employed. 

The following formula for a clyster has given more satisfaction in my 
practice than any other which I have employed : 

B- Argent, nitrat., gr. iv ; 
Bismuth, subnitrat., 5ss; 
Mucil. acaciae, 
Aquae, aa 1 ij. Misce. 
One-quarter to one-half of this should be used at a time, with the addition of 
as much laudanum as is thought proper, and it should be retained by a com- 
press, held by the nurse. 

In most of those cases of intestinal catarrh which occur under the de- 
pressing effect of warm weather, alcoholic stimulants are required almost 
from the commencement of the disease, and their use is beneficial in 
chronic or protracted cases, whatever the cause or season. Bourbon 
whiskey or brandy is the best of these stimulants, and it should be given 
in small doses, repeated at intervals of two hours. I have usually ordered 
three or four drops to an infant one month old, and an additional drop or 
two drops for each month. The stimulant is not only useful in sustain- 
ing the vital powers, but it also aids in relieving the irritability of stom- 
ach. 

In certain cases vomiting is a prominent symptom. It is common and 



716 INTESTINAL CATARRH OF INFANCY. 

often obstinate in cases occurring during the summer epidemic, and it 
increases greatly the prostration. Sometimes it is due to excess of acid 
in the stomach, sometimes it is the result of the general irritability and in- 
creased movement of the gastro- intestinal canal, and sometimes it has a 
cerebral origin. The following are formulae which will be found useful 

for this symptom : 

B. Bismuth, subnitrat., 3 ij ; 
Spts. ammoD, aromat., 3ss; 
Syr. simplic, 
Aquae, aa 1 j. Misce. 
Shake bottle. Dose, one teaspoonful hourly, or every second hour if required, 
make cold by a piece of ice. 

B. Acid, carbolic, gtt. ij ; 
Aq. calcis, |ij. Misce. 
Dose, one teaspoonful with a teaspoonful of milk (breast-milk if the baby 
nurse), to be repeated according to the nausea. 

Lime-water alone often removes the nausea when there is an excess of 
acids in the stomach, but it is rendered more effectual in certain cases by 
the addition of carbolic acid, which tends to check any fermentative pro- 
cess. 

Another remedy is the neutral mixture, prepared by the following 
formula, the bottle being tightly corked immediately on mixing the in- 
gredients, so as to retain the carbonic acid : 

B. Potass, bicarbonate, gr. xxv ; 
Acid, citric. , gr. xvij ; 
Aq. amygdal. amarse, § j ; 
Aquae, 1'\]. Misce. 
Dose, one teaspoonful to a child from eight to ten months, according to the 
nausea. The carbonic-acid water of the shops, given ice-cold, may be equally 
useful. 

Dr. Sweezey, formerly one of the attending physicians in the class of 
children's diseases at the Out-Door Department at Bellevue, and who has 
called my attention to the good effects of minute doses of ipecacuanha 
to relieve nausea in this disease, employs the following formula : 

B. Tinct. ipecacuanhae, gtt. iv ; 
Aquae, 1 iv. Misce. 
Dose, one teaspoonful, repeated according to the nausea. 

I have employed all these prescriptions, and in certain cases with a sat- 
isfactory result, but my preference is for the bismuth in large doses, as it 
seems to afford relief in the largest proportion of cases. Nevertheless 
there are instances, especially during the summer epidemics, when this 
symptom is very obstinate, and all these remedies may fail. In these 
cases perfect quiet of the child, the administration of but little nutriment 
at a time, mustard over the epigastrium, and the use of an occasional 
small piece of ice may relieve the nausea. 



TREATMENT. 717 

When the catarrh is chronic, and the vital powers begin to fail, as indi- 
cated by pallor, more or less emaciation, and loss of strength, the follow- 
ing is the best tonic mixture with which I am acquainted. It aids in 
restraining the diarrhoea, while it increases the appetite and strength. It 
should not be prescribed until the inflammation has assumed a subacute 
or chronic character. 

B. Tinct. columbae, 3 iij ; 

Liq. ferri nitratis, gtt. xxvij ; 
Syr. simplic, § iij. Misce. 
Dose, one teaspoonful every three or four hours to an infant of one year. 

In the Out-Door Department at Bellevue we commonly give this tonic 
alternately with the bismuth powders. 

External Treatment. — Some writers recommend depletion by leeching 
in intestinal inflammation, advice likely to do harm, unless the particular 
cases are described in which it may possibly be of service. It can be 
useful only in those cases in which the infant is robust and of full habit, 
and the disease commences suddenly with decided febrile reaction. Such 
cases are oftenest seen with us in the winter season, and even these are 
ordinarily best treated without loss of blood. Sinapisms and poultices 
usually are sufficient as local measures. In these cases, also, the warm 
mustard foot-bath should be employed, and repeated if there be restless- 
ness or cerebral symptoms. 

In all forms of intestinal inflammation in infancy and in all its stages 
mild counter-irritation over the abdomen is often useful, but vesication, 
by increasing the restlessness of the infant and reducing its strength, 
without materially modifying the severity or duration of the disease, does 
more harm than o-ood. It is not to be thought of as a remedial measure. 
I have known a troublesome sore continuing till death, and probably has- 
tening this result, to occur from this treatment. Poultices or fomentations 
over the abdomen are sometimes beneficial, especially those of a mildly 
irritating nature. A poultice of powdered cloves, cinnamon, and ginger, 
or of linseed meal to which a little mustard is added, may be employed, 
or a linseed poultice spread, thin, under which a single layer of muslin is 
placed, saturated with camphorated oil or tincture of camphor, and over 
both oil silk. In the entero-colitis of infants, occurring in the cool 
months, and due to exposure to cold, this treatment is especially useful. 
In the epidemic entero-colitis of the summer months, which may be 
aggravated by heat, treatment by poultices may be injudicious, but in 
such cases it is proper to produce moderate redness over the abdomen by 
temporary applications. 



18 ENTEKITIS AND COLITIS IN CHILDHOOD. 



CHAPTEK IX. 

ENTEKITIS AXD COLITIS IX CHILDHOOD. 

Intestinal inflammation in childhood differs materially from the form 
or type which it commonly presents in infancy. Its causes, symptoms 
and extent vary in important particulars in the two periods. In child- 
hood there is not ordinarily such extensive inflammation of the mucous 
membrane of the intestines as we have seen is present in the majority of 
cases in infancy, and it may, therefore, be properly treated as two dis- 
eases, according to the seat of the morbid process, namely, enteritis and 
colitis. Both these affections in the child resemble so closely the form 
which they exhibit in adult life, that no extended description is needed in 
this connection. 

Causes. — A main cause is sudden reduction of temperature by expos- 
ure to cold, or to currents of air, which checks perspiration, and causes 
determination of blood from the surface to the viscera. These inflam- 
mations are also caused sometimes by irritating substances in the intes- 
tines. I have know fascal accumulations as well as worms to produce 
severe dysentery in the child, accompanied by the characteristic tenesmus 
and muco-sanguineous stools, and ceasing as soon as the offending sub- 
stances were expelled. The use of unripe or stale vegetables, if there be 
a strong predisposition to mucous inflammation, may be a sufficient cause, 
and some of the most dangerous cases are due to the accumulation in the 
intestines of seeds and the parenchyma of fruits. But the most common 
cause is that mentioned, namely, sudden exposure to cold when the body 
is heated, a danger to which children are especially liable, on account of 
the easy disturbance of the circulatory system in them, and their heedless 
exposure of themselves, unless incessantly watched. Enteritis and colitis 
are also frequently secondary diseases occurring in children as complications 
or sequela? of the eruptive fevers, especially measles. 

Symptoms. — The alvine discharges in enteritis and colitis in childhood 
are such as occur in these diseases at a more advanced age. In ente- 
ritis they are thin and of the natural color, or occasionally green ; in coli- 
tis they are more consistent than in enteritis, and are largely muco-san- 
guineous. Sometimes in enteritis, if the inflammation be not intense, the 
diarrhoea is slow in appearing, or it may be slight, so as not to attract 
^special attention. The disease may then resemble remittent fever, for 
which it is at times mistaken. The upper part of the small intestines is 
less frequently affected than the lower. If there be duodenitis, the flow 



DIAGNOSIS — PROGNOSIS — TREATMENT. 71£ 

of bile is occasionally impeded from tumefaction at the mouth, of the 
common bile-duct, and the icteric hue appears. In both enteritis and 
colitis there is abdominal tenderness, with more or less constant pain if 
the disease be severe, and in colitis, tormina and tenesmus. The pulse 
is accelerated, the heat of surface augmented, the face flushed, and, ex- 
cept in mild cases, expressive of pain. In many children at the com- 
mencement of the inflammation the nervous system is profoundly affected, 
as indicated by headache, stupor, twitching of the limbs, and sometimes 
by convulsions. The chief danger at the commencement of the disease 
is, indeed, from this source. Sometimes irritability of the stomach oc- 
curs, and the food is rejected, though much less frequently than in the in- 
testinal inflammation of infancy. Anorexia and thirst are common symp- 
toms. If the inflammation continue, there is soon perceptible emaciation, 
with loss of strength. The eyes become hollow, the face pallid, and the 
surface cool. Death may occur at an early period, the vital powers suc- 
cumbing from the intensity of the inflammation. In other cases, the 
acute disease ends in a subacute or chronic inflammation ; the patient be- 
comes gradually more reduced, till he dies in a state of extreme emacia- 
tion, such as we often observe in the entero-colitis of infancy ; or from this 
state he may recover by degrees, though perhaps with an irritable state 
of the bowels, which continues for months. In a majority of cases, how- 
ever, enteritis and colitis in childhood, if properly treated, soon begin to 
yield, and they terminate favorably in one or two weeks. 

Diagnosis. — It is not difficult to determine the existence of the in- 
flammation. This is indicated by the fever, abdominal tenderness, and 
the relaxed state of the bowels. Whether the disease be enteritis or coli- 
tis is determined by the character of the stools, the seat of the tenderness 
and the presence or absence of tenesmus. 

Prognosis. — It has been stated above that enteritis and colitis in chil- 
dren commonly terminate favorably. The result depends not only on the 
extent and severity of the inflammation, but the constitution and pre- 
vious health. The inflammation is more serious when secondary than 
when primary. Extensive and great tenderness of the abdomen, features 
pallid, anxious, and expressive of suffering, pulse frequent and feeble, 
should excite the most serious apprehensions. Frequent vomiting also 
denotes a grave form of the disease. Stupor, and especially convulsive 
movements, show that the nervous centres are affected, and should make 
us guarded in the prognosis. Improvement in the disease, on which to 
base a favorable prediction, is apparent in the diminution of the tender- 
ness, improvement in the pulse and character of the stools, a more cheer- 
ful countenance, and less disrelish of food. 

Treatment. — This should be similar to that employed for the adult. 
In enteritis at the commencement of the disease, if there be reason to sus- 
pect the presence of any irritating substance in the intestines, and ordi- 



720 ENTERITIS AND COLITIS IX CHILDHOOD. 

narily in colitis, it is advisable to commence treatment by the use of some 
simple evacuant, like castor oil. After this our reliance, so far as internal 
treatment is concerned, must be mainly on opiate and antiphlogistic medi- 
cines. One of the best remedies of this class is the Dover's powder, 
which may be given to a child five years old in doses of three grains every 
three hours. A corresponding dose of any of the other opiates may be 
given, but with less sudorific effect. In colitis the occasional administra- 
tion of a laxative should not be neglected, if the stools be entirely or 
mainly muco-sanguineous. It should be employed so as to prevent accu- 
mulation of faecal matters in the colon, which would serve as an irritant 
and increase the inflammation. The dose should be small, merely suffi- 
cient to produce a faecal evacuation, and repeated as required, daily or less 
frequently. The laxatives commonly preferred are magnesia, rhubarb, or 
castor oil. The physician may prescribe an opiate mixture containing 
sufficient of the laxative to have the effect desired, though ordinarily it is 
better to prescribe the two separately, so that the laxative can be given 
or withheld, according to circumstances, while the opiate is continued 
more regularly. Except that there be some irritating substance which 
requires removal, the effect of laxatives is injurious, instead of beneficial. 
Most of the formulae given above in our remarks relating to the treatment 
of infantile intestinal catarrh, are likewise useful for the enteritis and coli- 
tis of childhood, the quantity of the opiate, which is the important ingre- 
dient, being increased according to the increase in the age. The follow- 
ing prescriptions may be employed for a child of five years : 

B. Pulv. opii, gr. v ; 

Bismuth, subnitrat., 3 ij. Misce. 
Divid. in pulveres No. xx. Give one powder every two to four hours. 
B. Pulv. ipecac, conip., 3j; 

Bismuth, subnitrat., 3ij. Misce. 
Divid. in pulveres No. xxiv. Give one powder as above. 
B- Tine, opii deodorat., 3ss ; 
Bismuth, subnitrat., 3 ij ; 
Aq. menth. piperit., 
Syr. zingiberis, aa |j. Misce. 
Shake bottle. Give one teaspoonful from two to four hours. 

The local treatment which is found most useful consists in the use of 
emollient applications covered with oil-silk, and made sufficiently irritat- 
ing by mustard or otherwise to cause constant redness. 

The diet should be bland and unirritating. In the first stages of the in- 
flammation, rice or barley-water, or arrowroot boiled in water, and simi- 
lar drinks should constitute the main diet. When the active inflamma- 
tion has abated, and at any period of the disease if there be a tendency to 
prostration, more nourishing food should be given. Milk and animal 
broths may then be allowed. In cases which are protracted, or attended 
with symptoms of exhaustion, alcoholic stimulants are required. 



CHOLERA INFANTUM. 721 



CHAPTER X. 

CHOLERA INFANTUM. 

Cholera infantum, or, as it is sometimes called, choleriform diarrhoea, 
is a disease of the summer months ; and, with exceptional cases, of the 
cities. It receives the name which designates it from the violence of its 
symptoms, which closely resemble those in Asiatic cholera. It is, how- 
ever, quite distinct in its nature, occurring independently of the epidem- 
ics of that disease. 

I have elsewhere stated that, as regards at least the city, the term chol- 
era infantum has been so extended as to embrace a large part of the diar- 
rhoeal maladies affecting infants in the summer months. Some physicians 
apply it even to mild but protracted cases of ordinary non-inflammatory 
or inflammatory diarrhoea occurring in the season mentioned. I employ 
it, and it should, in my opinion, only be employed, to designate that 
form of infantile diarrhoea in which there are frequent watery stools, ac- 
companied by vomiting, great elevation of temperature, and rapid and 
great emaciation. 

The number of deaths from cholera infantum reported in our bills of 
mortality is so large, while the number from the same disease embraced 
in the death statistics of European cities is so small comparatively, that 
some have been led to believe that this malady is much more prevalent 
and fatal in this country than in Europe, whereas, were these terms em- 
ployed in all places to designate precisely the same disease, probably no 
great difference would be found in the prevalence of cholera infantum on 
the two sides of the Atlantic. 

Causes. — It has been stated that cholera infantum prevails mainly in 
the cities and in the summer months. Cases occur from the month of 
May to October. Its maximum frequency and severity correspond with 
the degree of heat, and it is therefore most prevalent in the months of 
July and August. One of the chief causes of this disease is, doubtless, 
residence in an atmosphere loaded with noxious vapors, especially gases 
arising from animal and vegetable decomposition, or an atmosphere ren- 
dered impure by overcrowding and by personal and domiciliary unclean- 
liness. It is, therefore, much more common in tenement houses and 
parts of the city occupied by the poor than in cleaner and less crowded 
streets and apartments. 

Summer heat and the anti-hygienic conditions to which it gives rise in the 
cities, sometimes appear to be sufficient in themselves to develop cholera 
46 



722 CHOLERA INFANTUM. 

infantum ; at least it occurs Avithout other obvious cause. In other, and 
probably the majority of cases, another cause co-operates, namely, the use 
of improper food. Atmospheric heat and its depressing influences are 
then predisposing causes, while the use of indigestible or irritating food 
is the exciting cause. Infants upon whom both causes are operative are 
most liable to cholera infantum in its severe form. Hence bottle-fed 
infants of the city are especially liable to it, and infants whose food is 
carelessly and improperly prepared. Often in the hot months, acid and 
indigestible fruits, as currants, heedlessly given to an infant, occasion the 
attack. 

Cholera infantum occurs commonly under the age of two years. It is 
so frequent during the period of first dentition that some writers consider 
dentition a cause. At this period, however, as has been stated elsewhere, 
there is great functional activity, and rapid development of the intestinal 
follicles, and the peculiar liability to cholera infantum at this age should 
be attributed to this cause rather than to dentition. 

Symptoms. — Cholera infantum sometimes commences abruptly, the pre- 
vious health having been good. In other cases it is preceded by a pre- 
monitory stage, that of diarrhoea. The stools are thinner than natural, 
and somewhat more frequent, but not such as to excite alarm. Suddenly 
the evacuations become more frequent and watery, and the parents are- 
surprised and frightened by the rapid sinking and real danger of the 
infant. Occasionally this antecedent diarrhoea has continued several 
weeks, attended with emaciation and associated with intestinal inflamma- 
tion. 

This disease is characterized by the discharge of thin stools, designated 
by some watery, by others serous. The first evacuations, unless there have 
been previous diarrhoea, contain considerable faecal matter. They are so 
thin as to soak into the diaper like the urine, and in some cases they 
scarcely produce more of a stain than does this secretion. The odor is 
peculiar, not faecal, but musty and offensive ; occasionally the stools are 
almost odorless. Commencing simultaneously with the watery evacua- 
tions, or soon after, is another symptom, namely, irritability of the stom- 
ach, which increases greatly the prostration and danger. Whatever is 
swallowed by the infant is rejected immediately, or after a few minutes-, 
or there may be retching without vomiting. The appetite is lost, and the 
thirst is intense. Cold water, especially, is taken with avidity, and if the 
infant nurse, it eagerly seizes the breast, in order to relieve the thirst. 
The tongue is moist at first, and clean or covered with a light fur. The 
pulse is accelerated, while the respiration is either natural or somewhat 
increased in frequency ; the surface is warm, but its temperature is 
speedily reduced. There is no disease of infancy in which the tempera- 
ture of the blood is higher. In ordinary cases the thermometer intro- 
duced into the rectum rises above 105°, and I have seen it indicate 101°* 



ANATOMICAL CHARACTERS. 723 

The infant apparently experiences no abdominal tenderness or pain. It 
is often restless at first, but its restlessness is due to thirst, or that un- 
pleasant sensation which the sick feel when the vital powers are rap- 
idly reduced. The urine is scanty in proportion to the gravity of the attack. 

The loss of strength and the emaciation are more rapid than in any other 
diarrhoeal malady, except Asiatic cholera, and the most severe form of 
cholera morbus. The parents scarcely recognize in the changed and mel- 
ancholy aspect of the infant any resemblance to the features which it ex- 
hibited a day or two before. The eyes are sunken, the eyelids and lips 
are permanently open from the feeble contractile power of the muscles 
which close them, while the loss of the fluids from the tissues and the 
emaciation are such that the bony angles become more prominent, and 
the skin in places lies in folds. 

As the disease approaches a fatal termination, which often occurs in 
two or three days, the infant remains quiet, not disturbed even by the 
flies which alight upon its face. The limbs and cheeks become cool ; the 
eyes bleared, pupils contracted, and the urine scanty or suppressed. As 
death draws near the respiration becomes accelerated from the pulmo- 
nary congestion consequent on the feeble contractile power of the heart, 
the pulse becomes more and more feeble, the surface has a clammy cold- 
ness, and stupor results, which becomes more and more profound, and 
from which it is impossible to arouse the infant. 

In the most favorable cases cholera infantum is checked before the 
occurrence of these fatal symptoms, and often even in cases which are 
ultimately fatal, there is not such a speedy termination of the malady. 
The choleriform diarrhoea abates, and the case becomes one of ordinary 
entero- colitis as described in the foregoing pages. 

Anatomical Characters. — Rilliet and Barthez, who of foreign writers 
treat of this disease at greatest length, describe it under the name of gas- 
trointestinal choleriform catarrh. " The perusal," they remark, " of 
the anatomico-pathological description, and especially the study of the 
facts, show that the gastro-intestinal tube in subjects who succumb to this 
disease may be in four different states : (a), either the stomach is soft- 
ened without any lesion of the digestive tube ; (6), or the stomach is 
softened at the same time that the raucous membrane of the intestine, 
and especially its follicular apparatus, is diseased ; (c), or the stomach is 
healthy while the follicular apparatus, or the mucous membrane, is dis- 
eased ; (d), or, finally, the gastro-intestinal tube is not the seat of any 
lesion appreciable to our senses in the present state of our knowledge, or 
it presents lesions so insignificant that they are not sufficient to explain 
the gravity of the symptoms. 

" So far the disease resembles all the catarrhs, but what is special is 
the abundance of the serous secretion, and the disturbance of the great 
sympathetic nerve. 



724 CHOLERA INFANTUM. 

" The serous secretion, which appears to be produced by a perspiration 
■(analogous to that of the respiratory passages and of the skin) rather than 
by a follicular secretion, shows, perhaps, that the elimination of sub- 
stances is effected by other organs than the follicles ; perhaps, also, we 
ought to see a proof that the materials to eliminate are not the same as in 
simple catarrh. Upon all these points we are constrained to remain in 
doubt. We content ourselves with pointing out the fact." 

American writers divide cholera infantum into three stages, the first 
characterized by turgescence of the intestinal follicles, with more or less 
softening of the mucous membrane. In the second stage the mucous 
membrane of the intestines is vascular in patches and streaks, and some- 
what thickened and softened, while the solitary glands and patches of 
Peyer present an inflammatory hyperemia, and occasionally certain of 
them are ulcerated. In the third stage the brain is involved. The cra- 
nial sinuses, veins, and capillaries of the brain are congested, and transu- 
dation of serum occurs upon the surface of the brain or in the ventricles. 
The following observations show the character of these lesions : 

On the 1st of August, 1861, I made the autopsy of an infant sixteen 
months old, who died of cholera infantum, with a sickness of less than 
one day. The examination was made thirty hours after death. Nothing 
unusual was observed in the brain, unless, perhaps, a little more than the 
ordinary injection of vessels at the vertex ; no disease of stomach and 
intestines except enlargement of the patches of Peyer as well as the soli- 
tary glands ; mucous membrane pale. In this and the following cases 
there was apparently slight softening of the intestinal mucous membrane ; 
but, whether it was pathological or cadaveric is uncertain, as the weather 
was very warm. The liver seemed healthy. Examined by the micro- 
scope, it was found to contain about the normal amount of oil-globules. 

The second case was that of an infant seven months old, wet-nursed, 
who died July 26, 1862, after a sickness also of about one day. He was 
previously emaciated, but without any definite ailment. The post-mor- 
tem examination was made on the 28th. The brain was somewhat softer 
than natural, but was otherwise healthy. There was no abnormal vascu- 
larity of the membranes of the brain, and no serous effusion within the 
cranium. The mucous membrane of the intestines was of normal appear- 
ance throughout, unless somewhat thickened and softened ; the solitary 
glands of the colon were prominent. The patches of Peyer were not dis- 
tinct. 

In the New York Protestant Episcopal Orphan Asylum, an infant 
twenty months old, previously healthy, was seized with cholera infantum 
on the 25th of June, 1864. The alvine evacuations, as is usual in this 
disease, were frequent and watery, and attended by obstinate vomiting. 
Death occurred in slight spasms, in thirty-six hours. The exciting cause 
was apparently the use of a few currants, which were eaten in a cake the 



NATURE. 725 

day before, some of which fruit was contained in the first evacuations. 
The brain was not examined. The only pathological changes which were 
observed in the stomach and intestines were slightly vascular patches in 
the small intestines, and an unusual prominence of the solitary glands in 
the colon. These glands resembled small beads embedded in the mucous 
membrane. The lungs in the above cases were healthy, excepting hypos- 
tatic congestion. 

Since the dates of these autopsies, I have made others in cases which 
terminated fatally after a brief duration, and have uniformly found simi- 
lar lesions, namely, the gastro-intestinal surface either without vascularity 
or scantily vascular in streaks or patches, sometimes presenting a whitish 
or soggy appearance, and somewhat softened, while the solitary glands 
were enlarged so as to be prominent upon the surface. In cases which 
continue longer, evident inflammatory lesions soon appear, which are 
identical with those already described in the article which relates to intes- 
tinal inflammation. 

Nature. — It was formerly my opinion that cholera infantum is essen- 
tially non-inflammatory, but that it soon became inflammatory if not 
checked. Careful observations of its symptoms and lesions have since 
convinced me that it is the most violent inflammation to which infants 
are liable in our climate. There is no other infantile malady in which 
there is uniformly so high a temperature, and under which patients sink 
more rapidly. The alvine discharges to which the rapid prostration is 
largely due, probably consist in part of intestinal secretions, and in part 
of serum which has transuded from the capillaries of the intestines. It is 
well known to pathologists, that in inflammation of mucous surfaces of 
short duration, the redness is apt to disappear in the cadaver. 

The opinion has been expressed by certain observers that cholera infan- 
tum is identical with thermic fever or sunstroke. There is, indeed, a 
resemblance as regards certain important symptoms. In cholera infantum 
the temperature is from 105° to 108° ; in sunstroke it is also very high, 
often rising above 108°. Great heat of head, contracted pupils, thin faecal 
evacuations, embarrassed respiration, scanty urine, and cerebral svmptoms 
are common toward the close of cholera infantum, and they are the prom- 
inent symptoms in sunstroke. Nevertheless, I cannot accept the theory 
which regards these maladies as identical, and which removes cholera in- 
fantum from the list of intestinal diseases. In cholera infantum the' gas- 
tro-intestinal symptoms always take the precedence, and are, except in 
advanced cases, always more prominent than other symptoms. It does 
not commence as by a stroke like coup de soleil, but it comes on more 
gradually though rapidly, and it often supervenes upon a diarrhoea or 
some error of diet. In the commencement of cholera infantum the infant 
is not apt to be drowsy, and it is often wide awake and restless from the 
thirst. Contrast this with the alarming stupor of sunstroke. Sunstroke 



726 CHOLERA INFANTUM. 

only occurs during the hours of excessive heat, but cholera infantum may- 
occur at any hour, or in any day during the hot weather, provided that 
there be sufficient dietetic cause. Again, intestinal inflammation is not 
common in sunstroke, while it is the common, or, as I believe, the essen- 
tial, lesion of cholera infantum. These facts show, in my opinion, that 
the two maladies are essentially and entirely distinct. Nevertheless, cases 
of apparent sunstroke sometimes occur in the infant, and if the bowels are 
at the same time relaxed the disease is apt to be regarded as cholera in- 
fantum, and if fatal is usually reported as such to the health authorities. 
Such cases I have occasionally observed, or they have been reported to 
me, although they are not common. 

With the exception of the organs of digestion, no uniform lesion is ob- 
served in any of the viscera, unless such as is due to. change in the quan- 
tity and fluidity of the blood and its circulation. Writers describe an 
anaemic appearance of the thoracic and abdominal viscera, and occasional 
passive congestion of the cerebral vessels. The cerebral symptoms often 
present toward the close of life in unfavorable cases of cholera infantum 
may arise from that state of the brain known as spurious hydrocephalus, 
which is not attended by any uniform or certain lesion of this organ. 
As the urinary secretion is scanty or suppressed, cerebral symptoms may 
in certain cases be due to ursemia. 

Diagnosis. — This disease is diagnosticated by the symptoms, and espe- 
cially by the frequency and character of the stools. The stools have 
already been described as frequent, often passed with considerable force, 
deficient in faecal matter, and thin, so as to soak into the diaper almost 
like urine. The vomiting, thirst, rapid sinking, and emaciation serve to 
distinguish cholera infantum from other diarrhoeal maladies. 

When Asiatic cholera is prevalent, the differential diagnosis of the two 
diseases is difficult if not impossible. 

Prognosis. — This is one of those diseases in regard to which physi- 
cians often injure their reputation by not giving sufficient notice of the 
danger, or even by expressing a favorable opinion, when the case soon 
after ends fatally. A favorable prognosis should seldom be expressed 
without qualification. If the urgent symptoms be relieved, still the dis- 
ease may continue as an ordinary intestinal inflammation, which, in hot 
weather, is formidable and often fatal. If the stools become more con- 
sistent and less frequent, without the occurrence of cerebral symptoms, 
while the limbs are warm and pulse good, we may confidently express the 
opinion that there is no present danger. 

The duration of true cholera infantum is short. It either ends fatally, 
or it begins soon to abate and ceases, or it continues as an entero-colitis. 
Death may occur, in twenty-four or forty-eight hours, in a state of col- 
lapse, from the frequency of the stools, or not till after three or four 



TREATMENT. 727 

days. In general, if the case do not end within three or four days by 
recovery or death, it becomes one of severe ordinary entero-colitis. 

Treatment. — Cholera infantum requires, beyond most other diseases, 
the employment of proper remedial measures, from the earliest possible 
moment, since the infant rapidly sinks, unless the evacuations from the 
bowels be arrested, or rendered less frequent and watery. Regarding 
the disease as a violent intestinal inflammation, we have no difficulty in 
determining the therapeutic indications. Those already recommended 
in our article relating to intestinal inflammation, are indicated, and to the 
full extent which the infant will bear, without causing too much stupor. 
An infant between the ages of eight and twelve months should take one 
teaspoonful of the following mixture every two or three hours, till the 
vomiting and diarrhoea are controlled : 

£. Tinct. opii deodorat., gtt. xvj ; 
Spts. amnion, aromat., 3 j ; 
Bismuth, subnitrat., 3 ij ; 
Syr. simplic. , 5 ss. 
Mistur. cretae, 1 ise. Misce. 

An infant of six months can take one half the dose, and one of three or 
.four months, one third or one fourth the dose. Instead of this, one of 
the equivalent mixtures which are recommended for the treatment of in- 
testinal inflammation may be given. If cerebral symptoms appear, as 
rolling the head, drowsiness, etc., I usually write the prescription without 
the opiate, and it may then be given more frequently if the case require 
it, while the opiate prescribed alone is given more guardedly and at 
longer intervals. 

There is danger in this disease of the sudden supervention of stupor, 
amounting even to coma and ending fatally. In these cases the stools are 
generally suddenly checked, and the opiate might aid in producing this 
result. In a few instances which I can recall to mind, where death oc- 
curred in this way, the friends believed that the melancholy result was 
hastened by the medicine. If the evacuations are partially checked and 
there are signs of stupor, the opiate should either be omitted or given less 
frequently. Explicit and positive directions to this effect should be 
given. Eligible preparations of opium for this disease are paregoric, tinc- 
ture of opium, pulv. cretse comp. c. opio, and, if there be no irritability 
of stomach, Dover's powder. 

Certain writers recommend the employment of a purgative as prelimi- 
nary treatment, in order to remove any irritating substance from the in- 
testines. But delay in the use of remedies to check the evacuations in- 
volves too much risk. When the urgent symptoms are somewhat con- 
trolled, a moderate dose of castor oil may be prescribed if there be reason 
to suspect the presence of any irritating substance in the intestines. 



728 CONSTIPATION. 

By this mode of treatment the stools are generally in a few hours ren- 
dered less frequent and more consistent. 

Certain physicians believe that calomel in small and repeated doses 
has a beneficial effect in choleriform diarrhoea, but those who use it 
employ it in combination with opium, and it is probable that the good 
effect observed is mainly due to the latter remedy. From the anatomical 
characters of cholera infantum there is apparently no indication for a. 
medicine that affects the function of the liver, and there is no evidence 
that calomel exerts any good effect on the follicular apparatus of the in- 
testines, which, so far as we can localize the disease, seems to be most in. 
fault of any part of the digestive apparatus. On theoretical grounds,, 
therefore, I should oppose the employment of this agent, and my observa- 
tions of its effects have been such that I entirely discard its use while we- 
have other safe and efficient remedies to meet every indication. 

Ordinarily, as the diarrhoea is relieved, the vomiting ceases. The rem- 
edies employed for the former are also curative of the latter ; still the- 
vomiting, if frequent and obstinate, sometimes does require special treat- 
ment, and we have no better anti-emetic mixtures than those recom- 
mended in our remarks on the treatment of intestinal inflammation. In- 
robust infants, at the commencement of the attack, small pieces of ice 
taken in the mouth, aid in diminishing the irritability of stomach. Mus- 
tard should also be applied to the epigastrium. 

In most cases alcoholic stimulants are required. The best of these is. 
Bourbon whiskey or brandy, which should be used from an early period 
of the disease. Aside from its sustaining the vital powers, it aids also in. 
relieving the irritability of stomach. 

The diet in cholera infantum should be simple but nutritious. That 
recommended for intestinal inflammation is proper for infants with this 
malady. 

Constipation. 

The gastro-intestinal portion of the digestive apparatus has a double- 
function. First, it receives and retains the food during the process of 
digestion ; it furnishes the most important of the liquids by which diges- 
tion is effected, and it absorbs those products of digestion which, are re- 
quired for the nutrition of the body, while it serves as a barrier against 
the admission of refuse matter. Secondly, it has an excretory function,, 
so that a large part of the waste and noxious products of the system are 
eliminated from its surface. Having, therefore, a relation so> close and 
fundamental to the general nutrition, it is necessary, for the normal 
activity of the organs and the maintenance of health, that its functions 
be regularly and fully performed. But retention of faecal; matter beyond 
the normal period is one of the most common ailimente both* in. infancy 
and childhood, and occasionally it constitutes a grave; disease.. 



CONSTIPATION. 729' 

Constipation is of two kinds, namely, symptomatic and idiopathic. 

Symptomatic Constipation. Causes. — Many of these are obstructive. 
The more common of them are the following : (a) Congenital stenosis, or 
occlusion of the anus or rectum. The anus is not formed, or it termi- 
nates in a cul-de-sac, while the lower end of the large intestine forms an- 
other cul-de-sac. These two cul-de-sacs, lying opposite each other, one 
looking upward and the other downward, may be separated from eack 
other by a small interspace, a fibrous septum, so that relief can be ob- 
tained by a puncture or incision, or they may be widely separated, so that 
there is no possible mode of relief, and death is inevitable, unless the 
fsecal matter escape through a congenital fistulous passage upon one of 
the adjacent mucous surfaces, which mode of relief was present in forty 
per cent of the cases of this obstruction collected by Leichtenstern. Ex- 
ceptionally this malformation occurs in the sigmoid flexure, while the rec- 
tum is normal. The stenosis, if slight, may produce little delay in the 
evacuations, except when hardened masses or coarse, indigestible sub- 
stances descend upon it, and it may, therefore, with careful selection of 
diet, cause little inconvenience for a lengthened period, while much steno- 
sis causes early obstructive symptoms. 

Rarely the stenosis is at the ileo-csecal orifice. Thus, in the Transac- 
tions of the Lond. Path. Soc, for 1870, is the history of a case in which 
there was such narrowing of the ileo-coecal orifice, believed to be congen- 
ital, that a No. 9 catheter could barely be passed through it. The patient 
lived till his thirty-second year, having suffered from an early age with 
frequent attacks of colic and constipation. After his death, the ileum 
next to the ileo-caecal valve was found to have a diameter of seven inches, 
while the large intestine was much atrophied, and its entire lumen con- 
tracted from the long disuse. Occasionally, the narrowing occurs a little 
above the ileo-csecal orifice, and more rarely in the duodenum, at the 
point of union of the pancreatic or bile-duct with the intestine. In the 
last situation, the obstacle sometimes appears to be hypertrophied valvulse 
conniventes, the edges of two opposite folds becoming more or less adhe- 
rent. Such congenital intestinal obstructions, whether, as is probable, 
produced by inflammations in the foetus or from simple perverted nutri- 
tion ; whether arising from syphilitic cachexia or other cause, of course 
retard the evacuations, according to their locations and the degree of 
closure. The same degree of stenosis in the colon or rectum obviously 
causes more constipating effect than in the small intestine, since the ex- 
crementitious substance is firmer in the former than in the latter, and the 
latter have more mobility by which to overcome obstacles. 

(b) Intestinal Displacements. — These produce obstructions of a very 
painful and dangerous kind. Intussusception and external hernia are too 
well known to require description. Both are apt to produce complete 
obstruction if not soon relieved, but there are cases of intussusception in 



730 CONSTIPATION. 

children in which the displaced intestine remains pervious, and the evacu- 
ations occur with more or less regularity ; and the same is true of one 
form of hernia, namely, the congenital, which, although painful, seldom 
produces serious obstruction. 

Painful and dangerous occlusion and consequent arrest of alvine evacu- 
ations occasionally results from the imprisonment of a loop of intestine in 
an opening, usually congenital, in the mesentery or diaphragm, or from 
the knotting of one portion of intestine with another, as described by 
Leichtenstern, or again from the twisting of the intestine. Thus, in the 
Centralb. f. d. med. Wissensch., for April 24, 1879, Epstein and Soyka 
relate the case of a new-horn infant that died in the second week after 
birth with symptoms of obstruction. At the autopsy, a portion of the 
small intestine with its mesentery was found twisted upon its axis, from 
right to left, without any marked evidence of inflammation. 

(c) Substances which have been swallowed, or substances whose nuclei 
have been swallowed, and which consist of a deposit of carbonate and 
phosphate of lime, or substances which have been produced entirely in the 
system, and which, lodged in narrow parts of the intestine, cause ob- 
struction. Such substances, some of which occur most frequently in 
children, and others in elderly people, produce acute constipation. Indi- 
gestible matter contained in the food, as seeds or the parenchymatous 
portions of fruits, occasionally collect in considerable quantity and ob- 
struct the intestine. A large gall-stone, having escaped from the com- 
mon bile-duct, sometimes lodges in the intestine, either at the ileo-csecal 
valve or, more rarely, at some other point, and retards the passage of 
faecal matter. But this seldom occurs in children. 

In one instance, and in only one, have I known obstinate constipation 
to be produced by worms. The patient was a girl of about four years, in 
whom constipation came on suddenly, and was accompanied by disten- 
sion of abdomen and great suffering. This continued nearly one week, 
when a mass of intertwined round worms was expelled, with immediate 
relief. The records of medicine also contain cases in which neoplasms, 
growing from the coats of the intestines internally, have attained such a 
size as to retard the evacuations. 

(d) Abscesses and tumors, especially when occurring in the pelvis, also 
sometimes cause constipation by pressing upon the intestine, and ob- 
structing or narrowing the passage through it.. Thus, in 1868, Mr. 
Thomas Smith related to the London Pathological Society the case of an 
infant, aged fourteen months, in whom both alvine and urinary evacua- 
tions were retarded by a cancerous tumor growing between the rectum 
and bladder, and ending fatally in three months after the occurrence of 
the first symptoms. 

(<?) Peritonitis, during its continuance, is known to constipate the 
bowels. It is supposed that inflammatory oedema occurs around the 



CONSTIPATION. 731 

muscular fibres of the middle coat, by which their contractility is im- 
paired. Hence the lax state, the meteorism, and inaction of the intestines 
in this disease. When the peritonitis abates, the normal action is re- 
stored, and the evacuations occur regularly, if the free surface of the peri- 
toneum have undergone no unfavorable change. But unfortunately peri- 
tonitis often produces more lasting injury, so as to interfere seriously with 
the intestinal movements, and produce an habitually torpid state of the 
bowels. This occurs from adventitious bands of inflammatory origin, 
which lie across the intestines, compressing them at the points of contact, 
and restraining their movements, and from adhesion of the intestinal 
loops. 

The most marked cases which I have observed of this were children 
who had had tubercular peritonitis. The following was an interesting 
example : 

Charles, aged 4 years, was returned to the New York Foundling Asylum 
on April 16, 1877, to be treated for tumor albus of the left knee, and for 
general ill-health. His parentage and early history were unknown. The 
nurse in the city, to whom he had been intrusted when quite small, stated 
that he had no sickness when with her, except sore eyes, and that about 
April 1, 1877, the enlargement of the knee was first observed. The head 
of the boy was large, and the abdomen much distended, but without any 
decided tenderness on pressure ; its entire lower part had a purplish color. 
Percussion over it gave a dull sound, except upon and near the epigas- 
trium, where there was some resonance ; umbilicus prominent ; circum- 
ference of body over abdomen, 23 inches ; pulse 128 ; axillary tempera- 
ture 99°. It was stated that he had no stool without medicine, and that, 
usually, one tablespoonful of castor oil was required to produce it. The 
urine contained no albumen, and was apparently normal. As the appear- 
ance indicated struma, a mixture of cod-liver oil, syrup of the lacto-phos- 
phate of lime, and iron was prescribed, to be given three times daily, and 
directions were given to rub cod-liver oil over the abdomen also three 
times each day, for five minutes each time. Some nodules were felt, on 
pressure upon the abdomen, which we suspected were enlarged mesenteric 
glands. From the day on which the friction and kneading of the abdo- 
men was commenced, the stools began to occur, in the average, about 
twice daily. The kneading proved the safest, as well as most efficient, 
method of producing defecation. 

On May 4th, the circumference of the trunk over the most prominent 
part of the abdomen was reduced to twenty-two inches. The records on 
May 11th state : " Same treatment is continued ; has tolerable appetite, 
but is pallid, and his flesh flabby and soft." On May 22d, the circum- 
ference of the trunk gave 22f inches. The tumor albus remained about 
the same. 

I saw the patient again during attendance in the asylum, m August and 
November. The record in November states that he is feeble and failing ; 
is becoming weaker and thinner ; breath and exhalations from the surface 
offensive ; he is kept quiet on account of the knee. From this time he 
gradually failed, and died April 11, 1878. There was no cough to attract 
attention ; and instead of constipation, a diarrhoea of some weeks' con- 
tinuance preceded death. 



732 CONSTIPATION. 

Autopsy. —Lungs healthy, except a little exudation over the summit of 
right lung ; bronchial glands cheesy ; numerous tubercles, some of them 
cheesy, upon the parietal and visceral surface of the peritoneum. Loops 
of the intestines were united to each other by old adhesions, and the small 
intestines were generally bound down by bands into a " uniform con- 
glomeration ;" mesenteric glands enlarged and cheesy ; a large ulcer upon 
the surface of the rectum, and numerous small, round ulcers upon the sur- 
face of small and large intestines, apparently occupying the site of the 
solitary follicles. 

Occasionally, a false band, the result of peritonitis, lies across the intes- 
tines, without restraining their movements, and producing no marked 
symptoms, and probably no symptoms at all, until a loop happens to pass 
underneath it, when, if not soon released, it is apt to become strangu- 
lated, with complete obstruction to the passage of faecal matter. This 
displacement might properly be classified with the internal hernias de- 
scribed above. In my own person, at the age of twelve years, such an 
accident occurred about two months after the peritonitis. Upon the 
abatement of the inflammation, a sensation of traction had been noticed 
in the umbilical region, almost daily, during exercise, and the displacement 
was indicated by the extreme pain which characterizes such cases, and 
which ceased suddenly, when the parts were released after about eighteen 
hours. 

(/) While it is important that the diet and glandular secretions should 
be such that the feculent matter may have proper consistence, for easy pro- 
pulsion along the intestinal tube, the important agent by which alvine evacu- 
ations are effected is obviously muscular contraction. The muscular fibres 
of the intestines produce the vermicular and peristaltic movements, by 
which the excrement is carried forward, and the abdominal muscles, by 
their powerful contraction, are the chief agents of expulsion. Now any 
pathological state which impairs the innervation of these muscles, or ren- 
ders it abnormal, destroying the proper balance between u exciting and 
inhibiting impulses," is apt to cause constipation. Hence meningitis, 
myelitis, and certain other diseases of the cerebro-spinal axis, rachitis, 
general weakness, etc., are commonly attended by a sluggish state of the 
intestines, either from tonic contraction of the muscular fibres of the mid- 
dle coat, as in meningitis, or paralysis. 

Idiopathic Constipation. Causes. — These are quite numerous. The 
more prominent of them are the following. First, too little liquid in the 
excrement, so that it is too firm for ready evacuation. There may be too 
little liquid taken in the ingesta, or too scanty secretion of the liquids 
which mix with the food, as those of the pancreas, liver, and mucous fol- 
licles, or there may be too great an absorption of liquid through the coats 
of the intestines and too active an excretion of water from the skin, kid- 
neys, or lung. The firmer the faecal matter, the greater the tendency to 
constipation. Those who lose a large amount of water, as in diabetes, 



CONSTIPATION. 733 

night sweats, or from occupations which expose to heat, or from residence 
in a hot climate, are especially liable to constipation, except as the loss 
of liquid is compensated by an increased amount of drink. 

The character of the food, apart from the amount of liquid which it 
contains, obviously has a marked influence upon the consistence and fre- 
quency of the stools. Occasionally, the intestines act sluggishly from in- 
sufficiency of food. Thus, the infant sometimes hangs an unusually long 
time on the breast, and the mother or wet-nurse believes it to be a hearty 
nurser, when there is really deficiency of milk, and the stools are scanty 
and infrequent from lack of material. Again, constipation is not un- 
common in infants who nurse heartily, and seem to obtain a sufficient 
quantity of milk, and the cause of it is not in the state of the digestive 
organs, but in the milk. We find that now and then breast-milk has a 
constipating effect, although we discover nothing to cause this result in 
the mother's diet or health. The comparison of ordinary milk with co- 
lostrum may furnish a clue to the explanation. Colostrum is known to be 
more laxative than ordinary milk, and it differs from it chemically in con- 
taining more butter, sugar, and salts. Hence the theory seems plausible 
that, when breast-milk is constipating, these elements occur in less than 
the normal quantity. And we shall see hereafter that treatment suggested 
by this theory obviates the constipation. 

The use of a diet which consists chiefly of assimilable substances, as 
animal food, and from which, after the digestive process, little coarse and 
stimulating residuum remains, is obviously apt to produce a sluggish state 
of the bowels. On the other hand, coarse food, as fruits with their 
seeds, coarsely ground meal, etc., which stimulate the peristaltic action 
and the secretions, increase the number and frequency of the alvine dis- 
charges. 

Habit also exerts a decided influence upon defecation. One who, for 
whatever reason, neglects or resists the desire for a stool, soon becomes 
less conscious of the daily recurring need, and establishes a constipated 
habit. Constipation is more apt to occur in those who lead a quiet life 
than in those who are active. A constipated habit is established in 
many school children, by neglecting or repressing the desire for a stool, 
during the school hours. 

But there are cases in which there seems to be a constitutional tendency 
to constipation — a tendency quite independent of the usual conditions. 
Thus I have met children who were bright and active, free from obstruc- 
tion or disease which might retard the evacuations, apparently far from 
having sluggish muscular contractility, and so far as I could see with 
proper diet, and yet with defecation, except as it was produced by meas- 
ures employed, occurring no oftener than each second, third, or fourth 
day. 

But it must be borne in mind that what is constipation in one child may 



734 CONSTIPATION. 

not be in another, for occasionally one does well with only one evacuation 
every second or third day, while a large majority require daily defecation, 
in order to the maintenance of perfect health. 

In the adult, the sacculi or pouches which occur in the walls of the 
colon, produced by contraction of the longitudinal bands, acting at right 
angles to the direction of the circular fibres, and consisting of the internal 
and external tunics, without the muscular, become the receptacles for 
faecal matter in those who are constipated, and obviously tend to increase 
the constipation. In children these sacculi are much less developed rela- 
tively, and in young infants, whose intestines lack the longitudinal bands, 
are absent, so that this anatomical condition by which the passage of faecal 
matter is delayed, is unimportant as a cause of constipation in the young. 
Grautier of Geneva, Switzerland, states that an anal fissure is a common 
cause of constipation in children. Pain in defecation when such a 
fissure is present might induce children to resist the desire, and postpone 
the act, and thereby establish a constipated habit, but if such fissures 
are common in this country, except in syphilitic infants, they have 
escaped our notice. 

Constipation has a tendency to perpetuate itself, since retained feculent 
matter becomes more consistent and firmer, and the contractile power of 
the muscular tunic becomes weakened by long distension. Obviously, 
also, an abnormal length of the large intestine, so that it doubles on 
itself, whether congenital or the result of constipation, and a malposition, 
which diminishes the space occupied by the colon, and therefore increases 
its flexures, have a tendency to produce constipation. 

Symptoms. — When there is a mechanical cause, which retards the pas- 
sage of faecal matter, the acuteness of symptoms and the suffering are 
generally proportionate to the degree of obstruction. Symptomatic con- 
stipation occurring in an obstructive disease, whether adhesions, perito- 
neal bands, intussusception, knots or twisting of the intestine, incarcera- 
tion in a false passage, or from biliary or intestinal stones, or faecal masses, 
is attended by severe symptoms, such as intense colicky pain, vomiting, 
loss of appetite, and rapid prostration. The ingesta accumulate above the 
point of obstruction, producing distension of the intestine with faecal mat- 
ter and gas, while below the point of obstruction the intestine is soon 
empty. The symptoms indeed have the severity, and the state involves 
the danger, present in ordinary strangulated hernia ; while, from being 
internal and therefore less accessible for treatment, the danger is even 
greater. If the intestinal tract be narrowed, whether by a false ligament, 
the result of an old peritonitis, or other cause, and there be still pervious- 
ness, so that excrementitious matter passes by the obstruction, though 
slowly, and with more or less difficulty, the patient may be comparatively 
comfortable, if the food be such that no hard masses remain ; but accord- 
ing to the degree of stenosis, and the amount and coarseness of the faecal 



SYMPTOMS. 735 

matter, symptoms occur referable to the obstruction. If the excrement 
be propelled with difficulty through the narrowed part, the muscular coat 
above the obstruction gradually becomes more developed, from hypertro- 
phy of the muscular fibres, just as the heart enlarges from obstructive dis- 
ease of its valves, while below the obstruction the intestine atrophies, and 
its calibre diminishes from disuse. Colicky pains, accumulation of faecal 
matter above the obstruction, distension of abdomen, eructation of gas, 
vomiting, impaired appetite, and consequent decline of the general health 
are common results. There is constant danger in these cases that the 
narrow passage may become obstructed by faecal matter, if it happen to 
contain hard masses, or coarse indigestible substances. The gravest form 
of constipation is obviously that due to mechanical agencies which act as 
obstacles, but as the obstacles are numerous, differently located, and of 
different character, so there is great difference in the gravity of the cases. 
Idiopathic constipation generally comes on gradually. It at first 
attracts little attention and is neglected. The symptoms, of course, vary 
greatly according to the degree and stage of constipation. In mild 
cases, the retention is only in the rectum, or rectum and sigmoid flexure, 
and there are no marked symptoms except a sensation of fulness or dis- 
tension of these parts, which one or two evacuations relieve. Between 
these mild cases and the graver forms of constipation, there is every in- 
termediate grade, attended by symptoms proportionately severe. It is 
surprising sometimes to observe how long patients live with extreme con- 
stipation, though with constant suffering and ill-health, and, which I wish 
especially to be noticed in this connection, a large proportion of the fatal 
cases of idiopathic constipation occurring in adults, and recorded in the 
literature of the profession, began early in life, even in infancy, at which 
time they probably might have been relieved by proper remedial meas- 
ures, and a life of suffering prevented. This important practical fact 
shows the need of greater attention on the part of parents and nurses to 
the state of the bowels in children, that their sluggish action may be cor- 
rected before it becomes habitual, and those anatomical changes of dis- 
tension and muscular paralysis occur, which are with difficulty corrected. 
Thus among the older authenticated cases is one related by Dr. Copland, 
in his Medical Dictionary, from Renauldin. 

A medical officer in the French service was always costive from birth r 
he ate largely, but seldom passed a stool oftener than once in one or two 
months, and his abdomen assumed a large size. At the age of forty- 
two, his constipation was usually prolonged to three or four months. In 
1806, after medicines had been taken to procure a stool, which had not 
been passed for upward of four months, abundant evacuations continued 
for nine days, and contained the stones of raisins taken a twelvemonth 
before ; but the constipation returned. In 1809 the enlarged abdomen 
became painful, vomiting supervened, and he died at the age of fifty- 
four, having seldom, through life, passed more than four, five, or six 



736 CONSTIPATION. 

stools in the year. On opening the abdomen, a fibrous partition ob- 
structed the rectum, about an inch from the anus. 

A case quite as remarkable, and of recent date, occurred in the practice 
of Dr. Strong, of Westfield, N. Y., and was reported by him in the 
Amer. Journ. of Med. Sci., in 1874 and 1876. 

This patient, at the age of two years, usually had one stool in two 
weeks, and several years later only one in six weeks. When an adult he 
was treated by Dr. Strong, who found great distension of the abdomen, so 
that the lower ribs were pressed outward in nearly a horizontal direction, 
and the thoracic organs upward so that the apex beat of the heart was 
about one inch above the nipple. At this time, months elapsed between 
the stools, the longest interval being eight months and sixteen days. 
Defecation when it did occur lasted from two to four days, and was at- 
tended by violent gastric and intestinal pain, vomiting, and prostration. 
At one of these prolonged stools, forty pounds of faeces, resembling, as it 
usually did, chewed brown paper, were evacuated, the quantity being ac- 
curately ascertained by weighing the patient before and afterward. He 
had appetite and was able to do certain kinds of farm work during the 
year preceding his death, which occurred at the age of twenty-eight years. 
At the autopsy the colon was found to have a length of six feet and three 
inches, and a circumference of thirteen inches, while the lungs were 
pressed upward and backward, as when compressed by a pleuritic exuda- 
tion. 

While such extreme cases are infrequent, all physicians of experience 
are consulted from time to time by adults who have had habitual consti- 
pation from their earliest recollection, and these cases, that aggregate so 
large a number, might, there is little reason to doubt, have been pre- 
vented for the most part during childhood, when the habit was being 
formed. 

In long- continued constipation, in which there is a large fsecal accumu- 
lation, not only is the diameter of the colon increased, as stated above, 
but this part of the intestine becomes elongated. This may lead to 
change in its position, the curves of the sigmoid flexure extending farther 
to the right, and the central part of the transverse colon by its weight 
curving downward. This abnormal lengthening and the consequent curv- 
atures have a tendency to increase the constipation, as has been stated 
above in our remarks relating to the etiology. 

In these cases of extreme constipation, which, fortunately, are rare in 
children, as they are also in adults, the distension of the colon at the ileo- 
cecal orifice has a tendency to widen this orifice, so that the valve which, 
in the ordinary state, prevents the return of any substance which has once 
passed by it, is apt to become insufficient. The adjacent folds which 
constitute the valve become separated, so that, if vomiting and anti- 
peristaltic movements occur, fsecal matter may pass from the colon toward 
the stomach. In aggravated cases, in which there is retention of a large 



SYMPTOMS. 737 

amount of faecal matter, distension, muscular paralysis, etc., similar to 
those which we have seen produced in the colon, are apt to occur, though 
to a less extent, in the small intestines, especially in the ileum. 

Retained excrementitious matter accumulating in large masses evidently 
becomes an irritant, so that, by its pressure, it excites muscular contrac- 
tions, which, if ineffectual in propelling the mass, cause colicky pains. 
The retained faecal matter also undergoes more or less decomposition, pro- 
ducing gases which, by increasing the distension, also increase the pain. 

Any irritating substance applied to a mucous surface is apt to excite 
increased secretion from the mucous follicles or from the glands whose 
orifices connect with the mucous membrane at the point of irritation. 
Many familiar examples will at once be recalled to mind, as the denuxion 
from the nostrils from the use of snuffs, and increased mucous secretion 
and salivation from objects held in the mouth. In the same way, retained 
excrement, forming hard masses which press upon the intestinal surface, 
excite a secretion, and not infrequently produce thereby a diarrhoea which 
is conservative, and which may for the time unload the bowels, or it may 
remove a part of the scybalae, while the rest remain. Hence we some- 
times hear patients speak of having irregular evacuations, constipation 
alternating with diarrhoea. In aggravated cases, the pressure of impacted 
fasces sometimes produces inflammation of the surface, when, in addition 
to abdominal pain, there are tenderness on pressure and some, usually 
quite moderate, febrile movement. In cases which have terminated 
fatally, after a longer or shorter time, destruction of the mucous surface 
has been found in places, in consequence of the pressure and inflamma- 
tion. Thus, in the history of the French officer related above, it is stated 
that the inner surface of the distended intestine " presented gangrenous 
and ulcerated patches." We can readily believe that, as in cases of 
typhoid ulcerations, if the ulcers reach a certain depth, they may also give 
rise to localized peritonitis, and that occasionally perforation may result at 
the ulcerated or gangrenous point. The expulsion of hardened masses 
which have collected in the rectum is slow and painful, and accompanied 
by more or less tenesmus, which not infrequently causes a portion of the 
mucous membrane at the anal orifice to descend below the sphincter ani 
and protrude, by which haemorrhoids are produced. Occasionally, as I 
have observed in certain cases, the entire circumference of the rectal mu- 
cous membrane, to the distance of half an inch or more above the anus, 
becomes so loosened from its attachment to the connective tissue that it 
descends below the sphincter ani, and protrudes during each defecation. 
But this displacement, known as prolapsus recti, more commonly results, 
in children, from protracted intestinal catarrh, attended by diarrhoea, loss 
of flesh, and by diminished tonicity of the tissues. 

A beautiful and conservative provision in the system is that by which 
vicarious functions are established to relieve organs which imperfectly 
47 



738 CONSTIPATION. 

perform their part. While the intestinal surface is to a great degree 
eliniinative, so that noxious and effete products are largely expelled from* 
the system in the stools, it possesses also, in high degree, an absorbent 
function, as all who employ rectal alimentation are aware. Now, if the 
intestine fail to perform its function of defecation, and feculent matter 
collect within it, and begin to exert pressure upon the intestinal surface, 
more or less of the liquid portion is taken up by the vessels, and, entering 
the general circulation, finds a mode of escape through other emunctories. 
The general ill-health or languor, the furred tongue, headache, and foul 
breath which characterize these cases are, no doubt, due to the absorption 
into the blood, or retention in it of noxious products contained in, and 
which in part constitute, the feculent matter. The fact that patients may 
live for years with tolerable appetite, and with only one dejection every 
second or third week, receives explanation in the fact that other organs,, 
as the lungs, kidneys, skin, etc., act as depurants for such excrenienti- 
tious matter as can be taken up in a liquid or gaseous form by the intes- 
tinal surface. 

In infants, constipation, even when slight and temporary, often causes- 
f retfulness, which is indicated by the character of their cries and the move- 
ment of the thighs over the abdomen. Continuing for a time, it causes- 
more or less fever, and, in those young children who are liable to eclamp- 
sia, it predisposes to an attack, and it may be the chief cause.. 

Treatment. — If there be reason to suspect the presence of a mechanical: 
obstacle which prevents normal defecation, a careful examination; should 
be made, in order to discover, if possible, its nature and location. Often 
it is of such a nature that it cannot be removed, but its> constipating 
effects may sometimes be in a measure obviated. In the case related 
above, in which constipation continued from early childhood to adult 
life, and finally proved fatal, its cause was ascertained to be a septum, in 
the rectum, which probably might have been relieved by surgical meas- 
ures. In all cases of constipation, which the history shows may be pro- 
duced by mechanical causes, whether the obstruction be complete and the 
colicky pains and other symptoms severe, or there be occasional scanty 
evacuations, with but slight or moderate suffering, the history of the. 
patient should be obtained, in order to ascertain if there had been at any 
previous time symptoms of peritonitis or other pathological state which 
might throw light on the etiology. The abdomen and the usual sites of 
hernia should be carefully explored by palpation, and the rectum by the 
finger, large-size catheter, or rectal tube. A thorough examination thus- 
instituted, painless to the patient, will usually enable the practitioner to 
determine either the exact or probable obstacle, if any be present. 

The proper treatment of symptomatic constipation obviously requires- 
the removal, so far as possible, of the primary disease, or the cause, 
whether it be obstructive or otherwise, and we need not stop to consider 



TREATMENT. 739 

the special measures which are required, and will pass to the consideration 
of the treatment of idiopathic constipation. 

Hygienic Measures. — We have already alluded to the fact that habit 
has a powerful control over the action of the intestines, so that it is im- 
portant to obtain a daily alvine evacuation at a certain hour, and, by 
establishing the habit, the need will usually be experienced when that 
hour arrives each day. Many cases which become troublesome and obsti- 
nate might, no doubt, have been prevented, had this physiological law 
been heeded, and a daily evacuation obtained at a certain hour. The 
constipated habit, mild and not yet fully established, is more apt to be 
overlooked when it occurs in childhood than in infancy, for the infant is 
closely and constantly under observation, and it soon presents symptoms, 
as fever and fretf ulness, if it do not have the regular evacuation, while 
children over the age of four to five years tolerate better a sluggish state 
of the bowels, and are likely to be constipated for a considerable time 
before it is ascertained. They therefore require more attention, in this 
regard, than is usually bestowed by parents. 

The nature of the diet is obviously important, as certain kinds of food 
are more laxative than others. Chicken-tea, and, to a certain extent, 
beef and mutton tea, are laxative, and, made plainly, are, therefore, useful 
in connection with other articles. The various kinds of berries and fruits 
have also a decidedly stimulating effect on the intestinal surface, and aid 
in removing constipation. The apple scraped or baked, or apple-sauce, 
may be given to quite young children ; and for those that are older, cur- 
rants, cherries, and, among dried fruits, prunes and figs are laxative. 
Unfermented cider, in its season, which has been found so useful for 
adults, may also be given to children in moderate quantity, at least to 
those who have reached the age of two or three years. 

By the digestive process, starch, which is unassimilable, is changed into 
glucose, which can be absorbed and assimilated, and, from the small size 
of the salivary glands in the first months of infancy, it is believed that the 
salivary and pancreatic fluids are insufficient to convert starch into glucose 
except in very inadequate quantity. It appears, however, highly proba- 
ble that there is an epithelial ferment, which converts starch into sugar 
(see Chemical Phenomena of Digestion, by Charles Richet, Rev. des Sci. 
Med., Oct., 1878), so that young infants can digest starchy food. Never- 
theless, the theory that the infantile digestion, up to a certain age, is in- 
adequate to effect the change, led to the preparation of food for infants, 
in which the change of starch into glucose was accomplished by a chemi- 
cal process. Now glucose, given in considerable quantity, is laxative, and 
I have found it necessary to give the glucose preparation sparingly, and 
with other food in the hot months, when infants are so prone to diarrhoea. 
But this laxative effect renders the glucose preparations of the shops very 
useful in the treatment of habitual constipation of infants, whether we 



740 CONSTIPATION. 

employ the u maltose*' or " granulated sugar of malt," or the prepara- 
tions of Liebig's food. Of four constipated infants in the New York In- 
fant Asylum, to whom Horlick's " sugar of malt" was given, three were 
relieved. Any of the glucose preparations can be given quite freely to a 
constipated infant, without impairing the digestive function, or produc- 
ing other ill-effect, so long as no more than the normal evacuations are 
produced ; and I consider them among the best and safest of the foods 
for the relief of constipation in infants, but glucose or grape sugar is 
only feebly laxative, probably not more than cane sugar. 

Oatmeal is more laxative than most other kinds of amylaceous food. 
Made into a gruel and strained, it may be given to the nursing infant, 
and unstrained to those who are older. Bread or pudding from coarsely- 
ground or unbolted flour or meal, and vegetables which contain saline and 
fibrous substances, have a stimulating and laxative effect on the surface of 
the intestines, and, therefore, are useful for constipated children of the 
age of two or three years and upward. 

There can be no doubt that the free use of water in the ingesta mate- 
rially aids in relieving costiveness. In one of the numbers of the London 
Lancet, a physician asks the profession how to cure obstinate constipa- 
tion in adults. Among the replies, one physician suggests drinking a 
tumblerful of cold water on retiring to bed, and another tumblerful in the 
morning, and there can, I think, be little doubt that the laxative effect of 
the broths, gruels, fruits, and mineral waters is partly due to the amount 
of water which they contain. One of the chief causes of constipation we 
have seen is too great firmness or consistence of the stools, due to absorp- 
tion of the water, and if a larger quantity of water be swallowed during 
or after the meals than is removed by absorption, so that the stools have 
their normal or less than normal consistence, this cause of constipation is 
removed. An excess of water introduced into the system is to a great 
extent eliminated by the kidneys, and, in hot weather, by the skin, and, 
to a certain extent, exhaled from the lungs ; but experience shows that, if 
the amount of liquid received be so great that the vessels in the coats of 
the intestines continue in a state of repletion, only a certain part of it is 
absorbed, while the rest descends and mixes with the excrementitious 
matter. 

The simple expedient of allowing a liberal use of water, so useful in 
adult cases, doubtless also has a laxative effect in children, and its judi- 
cious use is proper for them. Another important aid in overcoming 
habitual constipation is frequent kneading of the abdomen. My atten- 
tion was first particularly directed to this in the treatment of the case re- 
lated above, in which obstinate constipation, occurring in a child of three 
years from peritoneal bands and adhesions, was to a great extent corrected 
by friction over the abdomen for three or four minutes at a time with 
cod-liver oil, three or four times daily. The manipulation probably 



TREATMENT. 741 

did the good, and not the oil, but the use of one of the oils for inunction 
renders the kneading less painful, and insures its more thorough perform- 
ance by the nurse. All obstetricians in certain emergencies stimulate 
the uterine muscular fibres to contraction by kneading the abdomen, and it 
is probable that the muscular fibres of the intestines are stimulated in a 
similar manner, so that the intestinal movements are increased by which 
feculent matter is carried forward. 

The external application of cold, so effectual in contracting the uterine 
muscular fibres, also stimulates the contractile power of the muscular 
fibres of the intestines. Cold-water bathing, the sudden application of a 
cloth wrung out of cold water to the abdomen, and in certain obstinate 
cases even the douche, may be used to stimulate the muscular coat of the 
intestines and the abdominal muscles, to greater activity. Trousseau says : 
" Before leaving the subject of the treatment of constipation, let me 
refer to the application of cold to the abdomen — a minor method, which 
I have seen recommended, and have myself prescribed with astonishing- 
success. On rising in the morning, let there be placed on the abdomen a 
compress of several folds soaked in cold water, and let it be separated 
from the clothes by a sheet of gutta-percha or caoutchouc. This compress 
ought to remain on for three or four hours." This recommendation by 
Trousseau is for adults, who are much less susceptible to the influence of 
cold than children. So prolonged an application of cold and wet to a 
child, even the most robust, would involve danger, while its application 
during the brief period occupied in an ordinary bath, with proper exer- 
cise afterward, or with other measures to prevent chilling, could have no 
ill-effect. 

Therapeutic Measures. — For temporary constipation and many cases 
that are habitual, enemata should be employed, since they promptly un- 
load that part of the intestines in which feculent matter is ordinarily re- 
tained, while they do not impair the appetite or produce the prostration 
which so often results from purgatives. For temporary constipation, a 
warm clyster may be given, and it commonly is more agreeable to the 
patient than one of lower temperature than the body. Among the ene- 
mata which have been found useful are castile soap, with molasses and 
water, salt and water, the various oils, as sweet oil, with or without castor 
oil, linseed oil, alone or with molasses, and the gruels, as that of oat-meal 
or corn-meal made thin. The belief that the frequent use of warm clys- 
ters produces a relaxing effect is probably correct, so that, if it be neces- 
sary to employ clysters often, in consequence of the torpid state of the 
intestines, cool water, the effect of which is tonic and stimulating, should 
be used. 

For infants, a clyster of one or two ounces usually suffices, adminis- 
tered by a gutta-percha or glass syringe, while for older patients a propor- 
tionately larger quantity is required, administered by preference through 



742 CONSTIPATION. 

a Davidson india-rubber or a fountain syringe. In certain long-contin- 
ued, aggravated cases, the frequent injection of a large quantity of tepid 
water is indispensable, in order to wash away the accumulation of faecal 
matter. Thus, in 1854, Mr. Gay exhibited to the London Pathological 
Society a boy of seven years, who at the age of three years had had 
typhus fever with dysenteric stools. After convalescence, he had habit- 
ual obstinate constipation, so that, when Mr. Gay began treatment, there 
had been no faecal evacuation for nearly four months, and the girth of the 
body over the abdomen was forty-nine inches, and yet the appetite and 
general health were not seriously impaired. The shape of the abdomen 
and the examination showed great distension of the rectal ampulla and the 
descending colon. Mr. Gay first distended the sphincter ani, so that it 
admitted a speculum, and through a rectal tube, well introduced into the 
colon, the excrement was repeatedly washed away, so that at the time of 
the exhibition of the boy to the Society, the measurement in girth gave 
only twenty-four inches. Evidently in cases like the above, no other 
treatment except repeatedly washing out the intestines with warm water 
would have answered, and the dilatation of the sphincter ani and the in- 
troduction of the speculum to facilitate the escape of faecal matter are 
noteworthy. 

Suppositories may sometimes be usefully employed in place of enemata ; 
cocoanut butter, molasses candy, or soap cut in shape of a pencil may be 
used for this purpose. In the adult, long-continued constipation is not 
very rare, in which the rectal ampulla becomes so impacted that it is 
necessary to use the anal curette, the handle of a spoon, or the finger in- 
troduced, in order to break up the masses, and allow them to pass. In 
children, necessity for such treatment is much more rare, but there are 
occasionally cases like that above described by Mr. Gay, in which it may 
be needed. Dr. Nagel states that the evil may be removed by the intro- 
duction of a suppository of brown gelatine. This is steeped in water for 
twelve hours, and having been thus softened, is introduced into the rec- 
tum, and an evacuation obtained. The doctor attributes the laxative 
effect to the hygrometric action of the gelatine. 

The known effect of the galvanic current in producing contraction of 
the uterine muscular fibres suggests its employment to relieve constipa- 
tion, by stimulating the muscles of the abdomen and the muscular coats of 
the intestines, and those who have employed it speak favorably of its use. 
Habershon says : " A galvanic current, transmitted through the abdomi- 
nal walls, induces a very speedy action, or rather emptying of the colon. 
. A case of partial paraplegia, in which injections did not act 
satisfactorily, and drastic purgatives were undesirable, was treated by a 
galvanic current passed through the abdomen every morning. In a few 
hours a free evacuation was produced without any discomfort. " But the 
constipation of children very seldom requires the use of galvanism. 



TREATMENT. 743 

The ordinary purgatives should not be given habitually to relieve a con- 
stipated habit. They are apt to irritate the intestines, causing a catarrh, 
or else the intestines become accustomed to their action, and a large dose 
is needed to effect purgation. Given habitually, they cannot fail, also, 
to disturb the digestive and nutritive processes. One or two doses for 
present relief, both in habitual or temporary constipation, is sometimes 
required, provided that an injection is for any reason not preferred. For 
this purpose, castor oil or a few grains of calomel mixed with syrup of 
rhubarb, the syrup of senna, or the compound liquorice-powder of the 
German Pharmacopoeia may be administered with advantage. But for 
habitual constipation I strongly advise to discard the ordinary purga- 
tive medicines, and if the measures of a dietetic or hygienic character, 
recommended above, are not sufficient, to employ such remedial agents 
as promote, or at least do not impair, nutrition. 

Belladonna, so highly recommended by Trousseau and others, I have 
often administered to children, especially in pertussis, in large doses dur- 
ing several consecutive days, but it has not seemed to me to have any de- 
cided purgative effect. Though it may be useful in certain mixtures for 
adults, our experiences in this country, with reliable preparations, cer- 
tainly have not been such as to justify its employment as the sole or main 
remedy for constipation. It diminishes reflex irritability, and may ren- 
der the action of purgatives less painful, but from its known physiological 
effects we cannot believe that it increases the intestinal secretions or the 
action of the muscular fibres, one or the other of which results we expect 
from the use of an agent which is really laxative. Why the effects of 
belladonna, in this country, differ so widely from those observed abroad, 
needs explanation. On the other hand, nux vomica and its active princi- 
ple, strychnia, are doubtless valuable adjuncts to purgative mixtures, from 
their effect in increasing the action of muscular fibres. 

Physicians are not infrequently at a loss what to prescribe for the habit- 
ual constipation of nursing infants, which is by no means infrequent. 
iBut recollecting that the colostrum is more laxative than ordinary milk, 
and that it differs from it in containing more sugar, salts (largely phos- 
phates), and butter, we have a hint, as stated above, as to what is prob- 
ably lacking in the milk, and what, therefore, should be supplied. I am 
in the habit of giving the oil, sugar, and salts in the following formula, 
.and usually with the desired laxative effect: 

B. 01. morrhuae, 2 parts, 
Aq. calcis, 
Syr. calcis lactophos, aa 1 part. 

One quarter, one third, or one half teaspoonful may be given with each 
nursing, or a larger quantity, as a teaspoonful or more, three times daily. 
Breast-milk with this addition becomes more nearly like colostrum in its 



744 INTESTINAL WOKMS. 

laxative properties, while it does not possess those properties of colostrum 
which disturb the digestive process. I know no agent of a medicinal 
nature which meets the indication so well as this for infantile constipa- 
tion. But in my practice I have found it necessary, in not a few in- 
stances, to rely mainly on simple enemata for the relief of the constipated 
habit, till the infants reached the age when a mixed diet was proper. 

The habitual constipation of older children may ordinarily be relieved 
by the remedies recommended above, but occasionally a more active pur- 
gative effect may be needed. Since the portion of intestine which is 
chiefly implicated in ordinary forms of constipation is the colon, it is 
evident that, if it be necessary to employ frequently any of the active 
purgatives of the pharmacopoeia, such should be selected as produce little 
or no irritation of the long tract of the small intestines, while they stimu- 
late the function of the colon. The aloetic preparations are preferable for 
this purpose, as the tincture of aloes and myrrh, or the simple tincture of 
aloes, which may be given in dose of part of a teaspoonful in a convenient 
syrup, as the elixir adjuvans of Caswell & Hazard, or in coffee or milk. 



CHAPTER XI. 

INTESTINAL WORMS. 

The belief has been prevalent in the profession in former times, and is- 
now among the people, that worms in the intestines constitute a frequent 
disease, especially in children. As pathology and the means of diagnos- 
ticating diseases are better understood, this idea has been gradually aban- 
doned by physicians and the intelligent portion of community. Still 
these parasites must be considered an occasional cause of serious derange- 
ments, and, in rare instances, a cause even of death. They indeed often 
exist in small number, without producing any appreciable deviation in the 
individual from the healthy state ; but the most common and best known 
species, when they have once effected a lodgment in the intestines of 
man, ordinarily grow and multiply so as to produce symptoms, and 
require medicines for their expulsion. 

So far as is now ascertained by observations in different countries, 
about fifty animal parasites make their abode in man. It is not improba- 
ble that the number will yet be found greater by observations in distant- 
uncivilized countries. Of these fifty, twenty-one reside in the alimentary 
canal (Heller), several of them being microscopic. Of those occupying 
the intestines only, the following species are specially interesting to the 
practising physician, on account of their relation — for the most part caus- 



INTESTINAL WORMS. 745 

ative — to certain pathological states, to wit : the ascaris lumbricoides, or 
round-worm ; the oxyuris vermicularis, or thread-worm ; the bothrio- 
cephalus latus, and three species of taenia, or the tape-worms, and the 
trichocephalus dispar, or whip-worm. 

Ascaris Lumbricoides. — The round- worm has a dingy reddish or yel- 
lowish-red color and a cylindrical form, tapering toward both extremities 
from the point of its greatest diameter, which is a little posterior to the 
middle. The dead worm is paler than the living. The anterior ex- 
tremity is tipped with three lips, between which and the body is a circu- 
lar groove. Between these three lips anteriorly is the aperture of the 
mouth, from which the oesophagus extends to the distance of one fourth 
to one third of an inch. The intestine, which has a light brownish color, 
extends from the oesophagus to near the posterior extremity of the animal, 
where it terminates in the anus. The females are in numerical excess of the 
males, and their size is also greater. The shape of the worm is like that 
of the common earth-worm, from which it derives the name lumbricus, but 
it is somewhat more pointed and its color paler red. The tail of the male 
worm is curved like a hook, while that of the female is straight. 

The total number of eggs contained in a fully developed female has 
been estimated at sixty millions. The eggs when immature are conical, 
and are attached to a longitudinal band ; when mature they are oval, with 
dark granular contents and a strong double shell, and their diameter is 
about yi F of an inch. They are expelled in countless numbers with the 
faeces, and at the time of expulsion are surrounded by an albuminous coat- 
ing stained with bile. Their vitality is retained under apparently very 
unfavorable circumstances, even for years. They hatch even after they 
have been repeatedly frozen or desiccated. 

The ascaris lumbricoides inhabits the small intestines, where it is rap- 
idly developed from the embryonic state. The remark made by Heller, 
that when found in the colon it is always dead, cannot be true, for many 
live worms are expelled in the stools. 

The round-worm, more than all other intestinal worms, is inclined to 
wander away from its usual abiding-place, namely, from the jejunum and 
ileum, producing symptoms of more or less gravity, referable to the part 
over which it crawls. It occasionally enters the stomach, from which it 
is vomited, or it ascends the oesophagus into the fauces, from which it is 
soon removed by the efforts of the individual. Cases are on record, one 
of which Andral witnessed, in which the worm entered the larynx, pro- 
ducing suffocation and speedy death. Mr. Tonnelle also witnessed such a. 
case. A child, nine years old, was suddenly seized with great difficulty 
of respiration and pain in the upper part of the chest. A. careful exam- 
ination of the thorax gave a negative result. Death occurred in from 
twelve to fifteen hours, and at the post-mortem examination a lumbricus 
was found filling the cavity of the larynx. M. Blandin, also, witnessed a 



746 INTESTINAL WORMS. 

case, when interne of the Hopital des Enfants. An infant was suffocated 
by one of these worms, which had penetrated as far as the right bron- 
chus. Very rarely they crawl from the fauces into the nasal passages. 
This worm is so strong and active that there is no recess or reflexion of 
the mucous membrane of the digestive apparatus which it could possibly 
penetrate, in which it has not been found. It has been discovered in the 
appendix vermiformis, in the pancreatic duct, in the common bile-duct, 
and even in the gall-bladder. The number of these worms found in the 
intestines is very various. There may be only one, or the number may 
be almost incredibly large. 

Thus, Barrier relates the case of an infant thirty months old, who died 
in Hopital Necker. It was believed to be tubercular. Numerous tumors, 
which could be felt in the abdomen, were supposed to be tubercular 
masses. On making the post-mortem examination, the mesenteric glands 
were found healthy, but the intestines throughout their entire extent were 
filled with lumbrici. The masses which, during life, were supposed to be 
tubercular glands, were found to consist of worms. The caecum, espe- 
cially, was greatly distended by them. The intertwining or collection in 
balls of these worms constitutes, indeed, one of the chief dangers, as it 
renders them so much the more difficult of expulsion. 

The round -worm possesses no organs of penetration, still, if the intes- 
tine be weakened by disease, especially by ulceration, it may, by pressure 
with its head, force an opening, through which it escapes into the cavity 
of the abdomen, causing peritonitis and death. This worm is commonly 
found, whether single or in masses, surrounded by mucus, which serves 
as a partial protection to the intestines. 

The portion of the mucous membrane in contact with lumbrici is often 
found inflamed, either from movements of the worm, or from pressure of 
a mass of worms, or even of a single worm in a confined position, as the 
appendix vermiformis. This inflammation, continuing and increasing, 
may end in ulceration, and thus a weakened spot be produced, which may 
be ruptured by simple pressure of the mouth of the worm. In this way 
are to be explained those apparent cases of perforation, which have led 
some observers to believe that lumbrici had actually the power of pene- 
trating the healthy coats of the intestines. The perforation is obviously 
most apt to occur in those who have been enfeebled, and whose tissues 
have been rendered less firm and resisting by antecedent disease, as by 
typhoid fever. 

M. G-uersant describes a case in which the appendix vermiformis con- 
tained an ulcerated opening, through which two round-worms had partly 
passed into the abdominal cavity, producing fatal perityphlitis. The effect 
of their impaction in this narrow cul-de-sac was much like that of a bean 
or seed lodged in the same situation. 

The ascaris lumbricoides has occasionally been found in the most 



INTESTINAL WORMS. 747 

remarkable locations, namely, in abscesses lying without the intestines. 
They have been known to effect a lodgment in the liver, and produce an 
abscess there, no doubt by crawling up and distending a bile-duct. 
Their lodgment in other viscera, which have no pervious connections with 
the intestinal tract, is probably accomplished through fistulous openings 
produced by inflammation which they had no part in causing, as, for ex- 
ample, in the bladder and kidneys, of which there are well-authenticated 
cases. Worm cysts in the abdominal walls have been found to occur in 
most instances in the usual site of hernias, namely, at the umbilicus in 
children, and in the inguinal region in adults. It is presumed, therefore, 
that the worms had entered hernial protrusions, from which they had 
passed by ulceration into the abdominal walls, and had there become 
encapsulated. 

The oxyuris vermicularis, or thread-worm, so called from its resem- 
blance to pieces of ordinary white sewing thread, is also frequent in child- 
hood, and is not infrequent in the adult. The length of the male oxyuris 
is from one sixth to one fifth of an inch ; that of the female from one 
third to one half of an inch. The posterior extremity of the male is 
blunt, and is curved, or rolled up, toward the abdomen ; that of the 
female is slender and pointed like an awl. 

The head of this worm is relatively broad, from an unusual thickness 
or fulness of the cuticle, and the mouth, surrounded by " three nodular 
lips, ' ' is situated in the centre of the extremity. The oesophagus extends 
backward from the mouth, gradually growing larger, like the segment of 
a long and narrow cone, and ending in a globular enlargement, which has 
been designated the pharynx. From the pharynx the intestine runs in 
nearly a straight line through the worm. 

The eggs are numerous, so completely filling the interior of the female 
as to conceal the organs from view. They are flattened on one side, but 
are rounded or convex on other parts of their circumference. One end is 
more pointed than the other, as in the eggs of birds. Certain of the eggs 
in the mature female are seen to be undergoing segmentation, preparatory 
to hatching, while others more advanced contain tadpole -shaped embryos, 
and others still contain worm-shaped embryos, either lying within the 
shells or protruding from them. The hatching and growth of this worm, 
which have been observed under the microscope, are very rapid under 
favorable circumstances. " I once," says Heller, " saw the metamor- 
phosis from the tadpole-shaped embryo to the worm-shaped embryo com- 
pleted in about one hour, ' ' but the usual time is longer. Leuckart saw 
oxyurides, one fourth of an inch in length, fourteen days after the eggs 
had been swallowed. 

Oxyurides may be developed so rapidly from eggs swallowed in the in- 
gesta, that they attain nearly or quite their full growth while still in the 
small intestines, so that, although their chosen residence is in the large 



748 INTESTINAL WORMS. 

intestines, some of them are not infrequently found in the ileum, and even 
in the jejunum, of full size and active. The part of the intestinal tract 
which the oxyurides prefer, and in which the largest colony of them 
reside, is the caecum and appendix vermif ormis, and not the rectum, as 
stated in most of the books, and in this situation, where they have been 
little disturbed, their habits and the relative proportion of the sexes can 
be best observed. But they are ordinarily found both in the caecum and 
rectum in the same individual, and, indeed, upon all parts of the interven- 
ing surface of the colon. 

The number of oxyurides in the individual varies greatly. They are 
occasionally so numerous upon the intestinal surface that they resemble 
fur, and when they are so abundant they are commonly found above the 
ileo-caecal valve as well as below it. The males are smaller and apparently 
more fragile and perishable than the female. Therefore in the rectum 
and other exposed situations, there is a numerical excess of the females ; 
but in reflexions of the intestines, where they are securely lodged, as in 
the appendix vermiformis, no marked difference has been observed in the 
relative number of the two sexes. Since the males are more delicate, 
transparent, and smaller than the females, they are more apt to be over- 
looked in a hasty post-mortem examination. 

The term tape-worm is applied to several species of the taenia, and to ac 
least two species of the bothriocephalus, but all except four, namely, the 
taenia solium, taenia saginata or medio-canellata, taenia elliptica or cucu- 
merina, and the bothriocephalus latus, are rare in Europe and North 
America, and are therefore of little interest to the practising physician. 

The tape-worm is an hermaphrodite, each segment containing the two 
sexual organs. The head, or scolex, is small, about the size of a pin's 
head, and segment after segment is produced by a budding process from 
the head. The segments are attached to each other at their extremities, 
and each segment as it becomes further and further removed from the 
head, by the formation of new intervening segments at the upper end of 
the chain, becomes also larger and more matured. The oldest segments 
having attained their full growth, are detached, and have an independent 
existence. A separation of the chain of segments at any point does not 
compromise the life of the parasite. If only the head remain uninjured 
the segmentation continues from it, and in time the former number of 
segments and former length of the chain are restored. This worm resides 
in the small intestines, the larger species sometimes extending from the 
upper part of the jejunum to near the ileo-caecal valve. 

The taenia solium is developed from an embryo, known as the cysticer- 
cus cellulosae, contained in the muscles of the hog. It has also been 
found in some other animals, as the dog, deer, and polar bear. It is a 
vesicle, about the size of a pea or small bean, having a delicate cell wall, 
and is nearly spherical, except as its shape is changed by compression be- 



INTESTINAL WORMS. 749 

tween the muscular fibres. At one point of the cell wall is a depression, 
attached to the inner surface of which, and lying within the cyst, is a 
whitish, pear-shaped, solid body, which is the head of the cysticercus, 
and is identical in appearance and character with the head of the taenia 
solium turned inside out. Many experiments have shown the close rela- 
tionship of the cysticercus and taenia solium, that they are two forms of 
existence of the same parasite. Segments of the taenia solium have been 
repeatedly fed to pigs, and the cysticercus produced in their muscles, though 
in what way the ovum or embryo passes from the stomach to the muscles is 
not known. On the other hand, swine flesh containing cysticerci has been 
fed to criminals who were soon to be executed, and after their death the 
taenia was found in their intestines. It is evident that this parasite occurs 
only in those who eat swine flesh, as sausages, either raw or but slightly 
cooked. 

The head of this species of taenia, which is about the size of a small 
pin's head, has at the top a conical protuberance, upon which is a corona 
of hooklets, arranged in two circles, the hooklets of the outer circle being 
smaller than those of the inner. The projecting points, however, of the 
two rows fall together, forming one circle. The hooklets are inserted 
into depressions in the head, and many of them have fallen out in most 
specimens which we have an opportunity of examining. The depressions 
in which the hooklets are lodged are often dark from pigmentation. 
Back of the circle of hooks are four sucking disks, which the worm is 
able to protrude and move freely. When protruded they appear as small 
tubercles with slender pedicles. The neck, which is slender and about 
one inch in length, shows no markings from commencing segmentation, 
and it is succeeded by very small and delicate segments, which gradually 
increase in size as the distance from the head increases. 

The mature segments (proglottides) vary in size accordingly as they are 
in a state of contraction or relaxation. When relaxed, their length is 
about half an inch and breadth one quarter of an inch. The genital organs 
are situated on the margin of each segment, a little posterior to the mid- 
dle, and there is an alternation in their location between the right and 
left margins in the chain of segments. The uterus lies in the centre of 
the segment, forming a longitudinal straight line. From seven to twelve 
branches are given off from each side of the uterus, and these divide and 
subdivide like the branches of a tree. The male genital organs lie in the 
same aperture or pore in the margin of the segment, with which the 
uterus and ovaries connect. 

The eggs of the taenia solium are globular, with a diameter of about 
^ th of an inch, and with thick shells, which are striated like Mosaic 
work by lines which cross each other. It is estimated that not less than 
50,000,000 eggs are contained in all the segments of a matured taenia. 

This parasite is very liable to abnormal development. In some instances 



750 INTESTINAL WORMS. 

two or more segments are fused together, and often they are stunted in 
their growth, or they contain holes, fissures, and flaws, either from their 
original development, or produced by rupture of the distended uterus. 
Again, rarely two taenia are blended, so that along the flat side of one 
chain another is united by the margin, so that a section of the double 
parasite resembles the Roman letter T or Y. The nutrition of the seg- 
ments is maintained through a vessel running the whole length of the 
worm, near each margin, and having communicating branches. 

The taenia saginata, designated also medio-canellata, is much larger, 
stronger, and thicker, both as regards the head and segments, than the 
taenia solium. When fully matured it measures eighteen feet. The 
diameter of the head is nearly one line (y^ inch). It is furnished with 
four strong sucking disks, but it lacks the circlet of hooks which charac- 
terizes the taenia solium. Instead of the hooks the head is furnished with 
a small frontal sucking disk. The heads of some specimens of this worm 
are free from pigment, but other specimens present various shades of 
pigmentation — from a slight staining to a jet black color. The neck is 
short, and very near the head are markings which indicate commencing 
segmentation. The matured segments vary in measurement when relaxed 
— from a length of eight lines and breadth of two lines, to a length of 
nine lines and breadth of three lines. As in the taenia solium the genital 
pores are situated on the margins of the segments, varying irregularly from 
side to side, and the uterus has lateral branches, which divide dichoto- 
mously. There is but little difference in the sexual apparatus of the taenia 
solium and taenia saginata, but the eggs of the latter are somewhat larger 
than those of the former, and are oval. 

The development of the taenia saginata is sometimes irregular, produc- 
ing monstrosities, as in the taenia solium. The embryos of this parasite 
occur chiefly in the muscles of ruminating animals, as the ox, sheep, goat,, 
etc., and therefore its presence in man is attributable to the use of the 
flesh of these animals, either slightly cooked or raw. The cysticercus of 
this species appears to be less tenacious of life than that of the taenia so- 
lium, and when it perishes it becomes changed into a greenish-yellow pulp,, 
surrounded by the capsule, and imbedded in the muscular or other tissue 
where it had lodged. 

It is easy to distinguish this worm from the taenia solium if the head be 
found, by its larger size, the larger size of its sucking disks, and the 
absence of the circle of hooks. The segments are distinguished by their 
greater size, and the greater number, and the dichotomous division of the 
branches of the uterus. This species occurs over a much greater area of 
the earth's surface than the taenia solium. 

The taenia elliptica or cucumerina is a more delicate worm than the 
preceding species, measuring, when fully grown, from seven to ten or 
eleven inches in length. Upon its head is a rostellum or beak, which 



INTESTINAL WOK MS. 751 

the worm is able to thrust forward, and on which are about sixty hooks,, 
irregularly arranged. The anterior portion of the parasite is very deli- 
cate, like a thread, and its segments are small, but as in the other species 
they become larger, as their distance from the head increases. The ma- 
tured segments which have a reddish-white color are readily detached, 
and when separated they move about actively. This taenia is also an her- 
maphrodite, and a genital pore containing a double set of genital organs 
is located on each margin of the segment. The taenia elliptica inhabits 
the small intestines of the dog and cat, and many children in different 
localities have been affected with it. 

Heller states that the segments of another and rare species of taenia,, 
which were expelled from a child of nineteen months, are preserved in 
the Museum of Pathological Anatomy in Boston. Nearly in the middle 
of the posterior half of each segment, is a yellow spot, namely, the 
receptaculum, full of ova, and, therefore, the name flavo-punctata has 
been applied to this worm. Little is known in regard to the taenia nana 
and taenia Madagascariensis, since they occur in distant countries. 

The bothriocephalus latus is the largest of the tape-worms, attaining the 
length of 15 to 24 feet. It is one of the most important of the intestinal 
parasites. The head has an almond-shape, or the shape of an elongated 
and somewhat flattened globe, its length being about one line, and its 
diameter from one third to one half a line. Running longitudinally along 
each flattened side of the head is a groove or fissure, containing the appa- 
ratus of suction. Those segments which are still in the process of 
growth, have a breadth three or four times greater than their length, 
while the matured segments are nearly square. The genital pore occurs 
in the centre of one side of the segment, and in the chain of segments all 
the pores are found on the same side. A brownish, rosette-shaped spot 
is observed at the site of each ripe pore produced by the convolutions of 
the uterus, and the numerous eggs which this organ contains. 

The egg, which is oval, has a thin shell, a light-brown color, and at 
one end of it is a lid or operculum, which is separated from' the rest of 
the egg by a well-defined line. At the hatching an embryo, provided 
with six hooks, escapes from the lid. When it has separated from the 
egg it is provided with an albuminous covering, from which cilia radiate 
in all directions, by the movement of which it is propelled. After a few 
days this covering is lost, and the embryo now moves about by amoeboid 
extension and contraction. It is believed that in this embryonic state it 
enters an aquatic animal, a mollusk or fish, where it undergoes further 
development, and from which it is received into the stomach in the food. 
The bothriocephalus occurs not only in man, but also in some of the do- 
mestic animals which eat fish, as the dog. This parasite is believed to 
be rare outside of Europe, and in Europe it is chiefly met in countries- 
bordering on inland lakes and seas. 



752 INTESTINAL WORMS. 

The trichocephalus dispar is comparatively unimportant to the phy- 
sician, since it is uncertain whether it materially impairs the health or 
produces symptoms. It inhabits the caecum, but in rare instances it has 
been found in the ileum and appendix vermiformis. The number of 
these parasites is usually small, but as many as seventy to one hundred 
have been observed in the intestine of the adult. 

The trichocephalus dispar occurs also in the monkey, and a very simi- 
lar, if not identical, worm has been found in the pig. It is not frequent 
in children, and it has not been observed in very young children. It oc- 
curs in man in every part of the globe, and in some countries, as Egypt, 
Nubia, and Syria, it is said to be very common. This worm, which is 
also sometimes designated the whip-worm from its shape, attains the 
length of one and a half to two inches, the female being longer than the 
male. Its anterior two thirds are thin, delicate, and flexible, like a small 
thread. The posterior one third, which contains the generative organs 
and intestinal canal, is considerably thicker, and it ends abruptly. On the 
under surface, extending nearly the whole length of the body, is a longi- 
tudinal band, the width of which is about one third the circumference of 
the body. In the female, the posterior or thick portion of the worm is 
slightly bent or curved like the stock of a hunting-whip, while that of the 
male is rolled in the spiral form. The digestive tube consists of an 
oesophagus, which extends through the anterior thread-like part, and the 
stomach and rectum which lie in the posterior thick division. The geni- 
tals of the female lie in the commencement of the thick portion, and the 
uterus, when distended with eggs, occupies nearly the whole of this sec- 
tion. In the male, the pore, which contains the genitals, lies in the pos- 
terior extremity of the thick part, where it forms a cloaca with the termi- 
nation of the intestinal canal. The eggs, which are numerous, are oval, 
brownish, and with a glistening protuberance at each extremity, giving 
them the shape of a lemon. They have great vitality, hatching after 
repeated desiccation and freezing. Their development from the egg is 
slow. It is believed that the trichocephalus is produced directly from the 
egg, which has lodged in the intestine, and, therefore, does not have or 
require an intermediate stage of preparation in another animal. This 
parasite resides in the caecum, but when many are present, some are 
found in the ascending colon, and occasionally a few are observed in the 
small intestine. 

The taenia is rare in early life, but it now and then occurs in young chil- 
dren. I have met cases in this city under the age of five years. Rosen and 
Bremser report cases between the ages of six and eleven years, and Hufe- 
land one at the age of six months. Wawruch collected 206 observations 
of taenia, in 22 of which the age was less than fifteen years ; the youngest 
was a girl of three years. A most remarkable case of taenia is reported 
in the Gazette MHicale of Paris in 1837. M. Muller was called to treat 



CAUSES — SYMPTOMS. 753 

a foster child five days old for slight constipation. The bowels were 
evacuated by the use of rhubarb, manna, and a few grains of salt, and in 
the excrement a foot and a half of taenia were discovered. This worm 
had evidently existed during the foetal life of the infant. 

A similar case was treated by Prof. Skene, in the Long Island Hospital, 
in September, 1871, and reported by Dr. Armor, in the New York Med- 
ical Journal. The infant was born September 3d, of a hearty Irish ser- 
vant girl. On the 7th it refused to nurse, and was observed to have a 
mild form of tetanus. On the 8th small doses of calomel having been 
given, followed by castor oil, two segments of a taenia solium were passed 
from the bowels, and on subsequent days ten more segments, after which 
the tetanus ceased. The remedies employed after September 8th were 
the oil of male fern and turpentine. The mother, who had presented no 
symptoms of taenia, was ordered an emulsion of pumpkin seeds, which 
" she faithfully took for twenty-four hours, at the end of which she 
passed over seventy segments of taenia." This case is interesting as 
throwing light on a possible mode of the production of taenia, quite differ- 
ent from the ordinary and recognized mode, and also as showing the 
causative relation of intestinal worms to tetanus infantum. 

Causes. — It is obvious that intestinal worms are developed from eggs 
or embryo, which are introduced into the stomach in the ingesta. The 
eggs of the ascaris lumbricoides have been found by Mosler in drinking- 
water (Virchow's Arch., 1860), but it is probable that in most instances 
they are contained in fruits and vegetables which are eaten raw. The 
eggs of the oxyuris vermicularis are received from some one who is him- 
self affected with the disease. Roth Zender and Heller state that they 
have frequently discovered ripe eggs of this worm around the nails of per- 
sons who were troubled with oxyurides, a fact readily explained from the 
itching which they cause. If these eggs are upon the fingers of the 
mother or nurse, it is easy to understand how they are acquired by the 
child. We can understand also why this worm is so common in degraded 
and filthy families. In reference to the etiology of the tape- worm nothino- 
need be added to what has been stated above, and little is known in refer- 
ence to the manner in which the eggs of the trichocephalus are received. 

Certain conditions of the intestinal surface favor the occurrence of 
worms. Thus children in advanced typhoid fever are not unfrequently 
affected with the ascaris lumbricoides. 

Symptoms of the Ascaris Lumbricoides. — These are in part constitu- 
tional and in part local, due to the mechanical effect of the entozoa on the 
coats of the intestines. Writers, especially Rilliet and Barthez, have de- 
scribed the symptoms supposed to indicate lumbrici with minuteness. 
Those of a constitutional character are the following : Features at one 
time flushed, at another pallid, and in some children of a leaden hue • 
lower eyelids swollen, and sometimes surrounded by a blue semicircle ■ 
48 



754 INTESTINAL WORMS. 

thirst, nausea, or even vomiting ; appetite diminished or augmented, or 
variable ; breath foul ; papillae of the tongue red and projecting ; pulse 
accelerated and irregular. Rilliet and Barthez state that they observed 
this irregularity of the heart's action in a boy three years old, at the time 
he was passing a large number of lumbrici. The irregularity afterward 
disappeared. Acceleration of the pulse and increase in temperature are 
common symptoms of these worms, and hence the popular belief in a worm 
fever. This fever is often remittent and mild, but occasionally it is con- 
tinuous and of a high grade. 

The symptoms pertaining to the nervous system are important. In 
mild cases these may be absent, as when there are few lumbrici, and the 
child is robust, and over the age of five years, but in severe cases certain 
neuropathic symptoms are frequently present, such as dilatation of the 
pupils, especially inequality of dilatation, to which Munro attached 
diaguostic value, strabismus, twitching of the muscles, clonic convul- 
sions, somnolence, headache, neuralgic pains, delirium. Rarely chorea, 
deafness, and paralysis, it is believed, may result. (M. Bouchut, Gaz. des 
Hopitaux, 1867.) In the Amer. Journ. of Med. Sci. for July, 1869, 
Dr. Leedom, of Montgomery County, Pa. , relates the case of a boy of 
seven years, who had night-blindness due to a large number of lumbrici 
in the intestines. By the employment of pinkroot and calomel these were 
expelled, and the blindness ceased. Hyperesthesia of the abdominal sur- 
face was present in a case which I attended, and which subsided as soon 
as the lumbrici were expelled. Grinding the teeth in sleep, and picking 
the nostrils, are symptoms to which families attach great value. Obser- 
vations, however, show that, though sometimes due to worms, they more 
frequently have another cause. 

The local symptoms or disorders, in other words, those having a me- 
chanical origin, are colicky pains, experienced chiefly in the umbilical 
region ; stools sometimes natural ; in other cases diarrhoea with fsecalor 
muco-sanguineous stools ; flatulence. M. Davaine, at a recent period, 
made the important discovery that the faeces of patients affected with 
worms contain the ova of the particular species present, in large num- 
bers. These ova, which have been described above, can be seen through 
a lens magnifying 150 diameters. 

In exceptional cases there are local symptoms, due to the presence of 
these worms in unusual situations, such as a crawling sensation in the oeso- 
phagus ; a sense of constriction in this tube or the pharynx ; nausea and 
vomiting ; a cough, especially if the worm have crawled to the upper part 
of the oesophagus ; rarely the most urgent dyspnoea, and probable suffoca- 
tion, if a lumbricus have entered the larynx. Earache, and perhaps con- 
vulsions if the worm have entered the Eustachian tube (Case Davaine, p. 
144). The most dangerous symptoms arise from the crawling of the 
worm into narrow openings. 



SYMPTOMS. 755 

The enteritis and colitis, to which these worms sometimes give rise, is 
ordinarily mild, but in rare instances ulceration occurs, which may be at- 
tended by profuse and even fatal haemorrhage. Occasionally very painful 
and dangerous constipation results from an accumulation of worms, in a 
ball or mass too large to be expelled, unless with much delay and suffer- 
ing, preventing the passage of faecal matter, and producing severe abdom- 
inal pains. The symptoms in these cases resemble closely those of in- 
tussusception. A marked example of constipation produced in this way 
occurred in a family with whom I am acquainted, and who then resided 
in the interior of this State. A little girl of three or four years was sud- 
denly affected with obstinate constipation. The physicians prescribed 
active purgatives, calomel among others, and finally croton oil, and vari- 
ous injections, without relief. There was great pain with distension of 
the abdomen, and death seemed inevitable, when, after the lapse of 
several days, a free evacuation occurred, and in the stool was a mass of 
worms firmly intertwined. 

Children often have lumbrici without any appreciable impairment of 
the general health, but their presence may intensify the symptoms of inter- 
current diseases, and greatly increase the danger. Thus I recollect two 
children of three and three and a half years, with pneumonitis, who, at 
the same time, had lumbrici, one passing in the course of a few days 
thirty and the other twelve of these entozoa. Both presented well- 
marked physical signs of pneumonitis, and, though they recovered, the 
febrile movement and nervous symptoms were apparently aggravated by 
the intestinal affection. One had convulsions in the commencement of 
the inflammation, followed by profound stupor and amaurosis, lasting- 
two or three days. 

Often the symptoms due to lumbrici coexist with those of a protracted 
and distinct intestinal disease. Thus, as we have seen, the intestinal se- 
cretions of typhoid fever and of chronic diarrhoeal maladies afford a 
nidus for the growth of worms, and accordingly, at an advanced stage 
of these diseases, lumbrici are common. 

The symptoms produced by the oxyuris vermicularis are somewhat 
different. These worms do not usually cause the fever, disturbed diges- 
tion, the colicky pains, or the dangerous nervous symptoms which arise 
from the presence of lumbrici. Nor do they, like lumbrici, endanger life 
by crawling into unusual situations. In one recent case, I could detect 
no other cause of chorea than the presence of oxyurides, and eclampsia 
has been attributed to them, but such a result is exceptional, if, indeed, 
the cause be rightly assigned. 

Although the caecum is the chosen abode of this worm, and here more 
than elsewhere it exists in its normal state, it is not certain that it pro- 
daces any appreciable symptoms in this part of the intestinal tract. 

The symptoms which render this the most annoying of all the intes- 



756 INTESTINAL WORMS. 

tinal parasites are produced "by those oxyurides, chiefly the females, 
which descend into the rectum, where by their active movements they 
produce intense itching. A small number of worms cause little inconve- 
nience, but when many are present in the folds of the rectum their crawl- 
ing produces such intense pruritus that the patient can with difficulty re- 
main quiet. Usually this symptom is most marked in the early evening, 
when the child is warm in bed. It sometimes causes onanism in the girl 
as well as boy. This symptom may be nearly or quite absent during the 
day, but it returns so regularly at night as to resemble and be mistaken for a 
periodical nervous affection. So eminent a physician as Cruveilhier con- 
fesses that he has made this mistake of diagnosis. In the female child 
the oxyuris occasionally passes from the rectum to the vulva, producing 
leucorrhoea. 

In many instances tape-worms exist in children as well as adults, who 
thrive and present no symptoms, but in other instances there is more or 
less disturbance of the digestive function, with an uncomfortable sensa- 
tion in the abdomen. This sensation is more noticed after fasting, or 
after the use of certain kinds of food, and it is diminished by a full meal. 
Great hunger and a feeling of faintness are also common according to au- 
thorities, but I have not particularly remarked this in children. Irregular 
action of the bowels, vomiting, and various nervous symptoms, as itching 
of the nostrils and anus, headache, tinnitus aurium, cardialgia, numbness, 
deafness, blindness, etc., have with more or less correctness been attrib- 
uted to the tape-worm. Certainly such symptoms occasionally arise from 
this cause, for they cease with the expulsion of the worm (see case of 
Ohorea, Medico- Chir. Rev., January, 1868). Intermittent colicky pains 
in the umbilical region were the only marked symptom in a child with 
taenia whom I recently treated. Since the cysticercus cellulosae is the 
embryonic form of the taenia solium, it is quite possible that individuals 
possessing the latter may be infected from its ova with the former, * so 
that symptoms which have been attributed to the intestinal parasite, have 
sometimes been due to the encysted embryo. We are unacquainted with 
the symptoms of the trichocephalus if any occur, and this worm is very 
rare in children. 

Diagnosis. — Bremser long since made the remark, and it has been re- 
peated by most writers on diseases of children, that there is no sign or 
symptom which affords positive proof of the presence of intestinal worms, 
except the expulsion of one or more. Late microscopic investigations 
have revealed, however, a pathognomonic sign, namely the presence of 
ova in the faeces, which indicate not only the nature of the disease, but 
the species of the worm. 

The symptoms and disorders produced by lumbrici may all occur from 
other causes. Still, if several of them be present, and a careful examina- 
tion disclose no other cause, the presence of worms should be suspected, 



PROGNOSIS — TREATMENT. 757 

provided that the child be over the age of two years. The microscope may 
then be used for diagnosis. A little tentative treatment, entirely safe to 
the child, will also determine whether the suspicion be correct. One or 
two doses of medicine, administered under such circumstances, like the 
surgeon's exploring needle, may reveal the nature of the disease, and in- 
dicate the means of cure. 

In case of the oxyuris vermicularis, the itching directs attention to the 
anus as the place of the disease, and here the offending entozoa may 
often be discovered by the eye. 

Prognosis. — Intestinal worms produce a fatal result in only a small 
proportion of cases. Oxyurides never prove fatal, unless in rare instances, 
through convulsions. The manner in which death may be produced by 
lumbrici has already been pointed out. 

In genera], when the nature of the disease is ascertained, the worms are 
readily expelled by treatment, and the patient restored to health. There- 
fore, if there be no complicating disease, the prognosis is good. 

Treatment. — Much injury has been done to children by the use of 
anthelmintics occasionally employed by physicians, but oftener by parents 
before the physician is called. Medicines of this kind are usually irri- 
tants, and, in many of those diseases which simulate the verminous affec- 
tion, but are distinct from it, there is already an irritated if not an in- 
flamed state of the intestinal mucous surface. 

Vermifuges administered under such circumstances obviously do harm, 
and in all acute diseases in which they are not required, even if their ac- 
tion be harmless, their employment is to be regretted, since it consumes 
time which is very precious. It is thus that many lives are lost by the 
use of anthelmintic nostrums, which are extensively advertised and which 
command a ready sale, inasmuch as the belief in the presence of worms as 
a frequent cause of disease pervades all classes. 

A safe rule, followed by many physicians, and it would be much better 
if it were general, is not to give anthelmintics unless the child have passed 
one or more worms, or their ova be found in the fasces, and not then if 
the symptoms seem to be referable to a coexisting disease. In doubtful 
cases in which the symptoms resemble those of worms, a purgative dose 
of calomel or calomel and rhubarb may be employed. It will generally 
bring away one or more lumbrici or a mass of ascaris vermicularis, if 
either species of entozoa be present. This purgative may be safely em- 
ployed if there be no previous diarrhoea or debility. If after one or two 
doses and a free purgation no worms be passed, anthelmintic remedies 
should not be given, for it is almost certain that none exist. 

A large number of medicines have, or have had, a reputation as anthel- 
mintics. Santonin, the active principle of the European wormseed, is 
one of the best, and is much employed in this country and in Europe. It 
is nearlv tasteless ; it may be given in powder, spread on bread with the 



758 INTESTINAL WORMS. 

butter. It is kept in sliops in one or two-grain lozenges, with and without 
calomel. It has the advantage of easy administration, and is destructive 
to both the round and thread worm. M. Bouchut considers it preferable 
to all other remedies in the treatment of the round-worm. " To children 
two years of age he administers it in doses of ten centigrammes (1.54 
grains), and in patients above this age the quantity is increased by five 
centigrammes (0.8 grain) for every additional year." He gives in ad- 
dition occasional doses of calomel or castor oil. In this country santonin 
is usually administered in one to three-grain doses, two or three times 
daily, with an occasional purgative. The purgative is required to aid not 
only in the expulsion of the worm, but also of the ova. In overdoses 
santonin causes vomiting, diarrhoea, and altered vision, so that objects ap- 
pear yellow, but in medicinal doses it produces no unpleasant conse- 
quences. Other medicines are preferable if there be symptoms of ente- 
ritis. For many years the anthelmintic most employed in this country 
was the pinkroot, the root of the Spigelia marilandica, an indigenous 
plant. It was not only prescribed by physicians, but employed by fami- 
lies as a domestic remedy. It is apt to cause, if the dose be large, cere- 
bral symptoms, as vertigo, dimness of sight, spasm of the facial muscles, 
stupor, and even convulsions. These effects less frequently occur if the 
pinkroot be given with a purgative, and it has been customary to admin- 
ister it in combination with senna in an infusion. A half ounce of 
spigelia with an equal quantity of senna is macerated for two hours in a 
pint of boiling water, and then strained. For a child two or three years 
old the dose is half an ounce to one ounce. So popular has this vermi- 
fuge been in this country, that probably a majority of the native-born 
adults in the States recollect the nauseating doses of pinkroot administered 
by anxious parents. Pharmacy now provides us with the same medicine 
in a more convenient and acceptable form, that of the fluid extracts : 

5- Fluid ext. spigel., f § j ; 

Fluid ext. sennse, ffss. Misce. 
One teaspoonful to a child from three to five years. 

The officinal fluid extract of spigelia and senna may be given in the 
same dose. Professor Procter recommends the addition of santonin to 

this extract : 

$. Fluid ext. spigel. et sennse, f |j ; 
Santonin, gr. viij. Misce. 

This is probably the best anthelmintic that can be employed for the 
destruction of the round-worm in uncomplicated cases, and it is also very 
useful in treating the ascaris vermicularis. Chenopodium is also a good 
anthelmintic. It is efficient, and at the same time one of the safest in 
case the mucous membrane be inflamed. If there be abdominal tender- 
ness, with stools too frequent, and thin, or mucous, and tinged with 



TEEATMENT. 759 

blood, I should prefer the chenopodiurn to most of the other vermifuges. 
To a child of three years five drops of the oil may be given three times 
daily. It may be continued for a longer period than would be safe for 
most of the other vermifuges. Twice a week, during its use, a mild 
purgative should be given, as castor oil, rhubarb, or magnesia, unless the 
bowels are open. It may be given dropped on sugar, or in a mucilagi- 
nous mixture. 

Dr. J. F. Meigs says : " I myself rarely give any other remedy than 
wormseed oil in slight and especially in doubtful cases, unless this has al- 
ready been tried and failed. From my own experience, I believe that this 
remedy is all-sufficient in a large majority of the cases that occur in this 
city, as these are almost always of a mild character, and as it not only 
produces the expulsion of the parasites when they exist, but also acts ben- 
eficially upon the forms of digestive irritation which simulate so closely 
the symptoms produced by worms. I am persuaded, indeed, that of all 
the cases that have come under my notice, in which it seemed probable 
that worms might be present, none were expelled in nearly half, and yet 
the signs of disturbed health have passed away under the use of the rem- 
edy." .... " The following is a very good formula for the ad- 
ministration of this remedy : 

"B. 01. chenopodii, gtt. lx vel f 3j ; 
P. g. acacise, 3 ij ; 
Syrup, simplic, lj ; 
Aq. cinnamom., 5 i j - Misce. 
" Give a dessertspoonful three times a day for three days, and repeat after several 
•days." 

In cases of protracted intestinal disease attended by an increased and 
vitiated secretion from the mucous surface, a state which often gives rise 
to worms, turpentine is one of the best anthelmintics. In fact, in some 
of these cases there is no good substitute for it. For example, a boy of 
about ten years, attended by myself, October, 1864, had reached or 
nearly reached the fourth week of typhoid fever, when he passed from his 
bowels a large quantity of blood. He was previously emaciated and 
weak, and there had been, as is usual in such cases, considerable diar- 
rhoea. The haemorrhage was attended with great prostration, from which, 
however, he partially rallied by the use of stimulants. On the following 
day an equally severe haemorrhage occurred, attended with coldness of 
the face and extremities and great feebleness of pulse, so that death ap- 
peared imminent. Turpentine was now administered every six hours, a 
few lumbrici were passed, and the case thenceforth progressed favorably. 
The mechanical effect of the lumbrici on the ulcerated surface of intestine 
had probably given rise to the ha3morrhage. Turpentine may be given in 
doses of from five to ten minims three times daily to a child five years 



760 INTESTINAL WORMS. 

old. Sweetened milk or sugar in powder is a good vehicle for it, or it 
may be given in a mucilaginous mixture. 

B. Spts. terebinth, rect., 3 ij ; 
01. limonis, gtt. v ; 
Mucil. gum acac., 
Syr. simplic. , aa 3 vj ; 
Aq. anisi, fi-ij. Misce. 
Dose, one teaspoonful every six hours. 

The following formula for the employment of this agent is recom- 
mended by Dr. Condie : 

B. Mucil. gum acac, ^ij ; 
Sacch. alb. , 3 x ; 
Spir. sether. nitr. , 3 iij ; 
Spir. terebinth, rect. , 3 iij ; 
Magnes. calcinat., 3j ; 
Aquae menthse, §j. Misce. 

It is useless to enumerate the many anthelmintic mixtures which have 
been extolled from time to time. Those mentioned above are the least 
nauseous, and will rarely disappoint the practitioner. One other antidote 
for the round- worm should be mentioned, as it has been much used and is 
efficient, namely cowhage. This consists of the bristles which cover the 
pods of the Mucuna pruriens, a tropical plant. The pods are dipped in 
plain syrup of the ordinary consistence, and the bristles are scraped off 
with the syrup. When enough of the medicine is added to render the 
syrup of the consistence of thick honey, it is ready for use. The dose is 
a teaspoonful every morning for three days, after which a cathartic should 
be administered. I have never prescribed cowhage. although it is not 
unfrequently ordered by physicians, and a popular nostrum consists 
chiefly of it. 

One affected with tape-worm is obviously cured only when the head of 
the parasite is expelled ; but, in the majority of cases which I have observed, 
the head has not been found in the evacuations, even when the treatment 
had effected a complete cure, as shown by the subsequent history. The 
chain of expelled segments commonly terminated very near the head. This 
I believe is the common experience if we trust the friends of the patient 
with the examination of the stools. The physician himself should search 
for the worm's head, the evacuations being preserved. The nurse should 
be directed to add a little carbolic or salicylic acid, and a sufficient quantity 
of water to nearly fill the vessel. The liquid should not be roughly 
stirred with a stick, as physicians are in the habit of doing, since this 
breaks the worm into small portions, and renders the inspection more 
difficult, but it should be shaken frequently so as to detach the segments 
and head if, it be present, from the faecal matter. After it has stood at 



TREATMENT. 761 

least five to ten minutes, the worm, which has greater specific gravity man 
water, sinks to the bottom, and the npper part should be poured off. 
This process must be repeated till the water is nearly colorless, after which 
search should be made for the fragments, and the head, if present, will 
be found. 

Since entire expulsion of the tape-worm is effected with difficulty, pre- 
paratory treatment for about forty-eight hours should be employed before 
the vermifuge is administered. During this time the patient should take 
a mild purgative once or twice, and such food, in moderate quantity, 
should be allowed as leaves little residuum, as beef -tea, milk, etc., with 
some stimulant, if the patient feel exhausted. There are three articles of 
food which experience has shown to be especially useful in this prepara- 
tory treatment, perhaps from a sickening effect which they produce upon 
the worm, namely, salt herrings, onions, and garlic. These may there- 
fore be taken as food in the twelve or eighteen hours preceding the em- 
ployment of the vermifuge, which it is ordinarily most convenient to ad- 
minister in the morning. 

The various taenicides recommended in the books are probably all 
more or less efficient, but the one which has given most satisfaction in 
the Out Door Department at Bellevue, where probably a larger number of 
these cases are treated than in any other place in this country, is the oil of 
male fern ; but it is found necessary to employ a larger dose than is 
recommended in some of the books. For a child of six years the dose 
employed is one to two drachms in any convenient vehicle, as the syrupus 
aurantii florum. This should be followed in about four hours by a dose 
of castor oil, which completes the treatment. Heller, a very high Ger- 
man authority, recommends koosso or its active principle koossin, in the 
use of which I have had no personal experience. The pumpkin-seed has 
also been employed at Bellevue and in other parts of this city, but it 
seems to be less efficient than the oil of the fern. If the chain of seer- 

o 

ments break near the head, and the head be not seen, it will be necessary 
to wait two or three months in order to determine whether the cure is 
complete. 

Since the symptoms produced by tne oxyuris vermicularis are referable 
chiefly to the rectum, and are caused by the active movements of the 
worm, the prompt and thorough use of enemata, which causes their ex- 
pulsion, is evidently required. Enemata are more effectual if used cool 
than if warm ; and since this worm inhabits the caecum as well as rectum, 
large enemata given through a long tube or a large catheter are more 
effectual, causing the expulsion of a larger number of worms than are ex- 
pelled by small enemata employed in the usual manner. Various sub- 
stances have been used for this purpose, as lime-water, table salt in water, 
turpentine in milk, decoction of aloe, decoction of garlic, etc. Heller 
says : " Simple water would do well for this purpose, for in a short time 



762 GASTRO-INTESTINAL HEMORRHAGE. 

it causes the worm to swell up and burst ; but that is not altogether with- 
out an injurious effect on the intestinal mucous membrane. Hence, Vix 
recommends a solution of castile soap, in distilled water, or rain-water, of 
the strength of one to two and a half grains to the ounce. This has no 
unpleasant action on the intestinal mucous membrane,' while at the same 

time it quickly destroys both the worms and their eggs Vix 

has tested all the medicines usually used in enemata, and has found the 
above solution of castile soap to be the most effectual. ' ' The use of the 
enema in the evening, although only a small quantity of liquid be used, so 
as to wash out the rectum, insures relief from the itching and sleepless- 
ness during the night. 

But it is undeniable that enemata alone do not effect a complete and 
permanent cure in a large proportion of cases, and hence those affected 
with this worm remain sufferers for years, having only a temporary 
respite, unless medicines be administered by the mouth. Those medi- 
cines which produce free watery evacuations appear to be the most effect- 
ual in dislodging and expelling oxyurides whose attachment to the intes- 
tinal surface is not strong ; therefore Heller recommends the saline pur- 
gatives " joined with copious draughts of water." 



CHAPTEK XII. 

GASTRO-INTESTINAL HEMORRHAGE, 

Haemorrhage from the capillaries is more frequent in infancy than at 
any other period of life, whether in consequence of the irregularity of the 
circulation and frequent congestions in the infant, or the greater delicacy 
and feebleness of the minute vessels at this age. Hemorrhage, generally 
capillary, from the gastro -intestinal mucous surface, occurs sufficiently 
often in the child, and especially in the infant, to render it a disease of 
some importance. It is more frequent the younger the individual. 

This haemorrhage occurs in three distinct pathological states : first, in 
the new-born infant from causes not fully ascertained ; secondly, from a 
pathological state of the blood or the vessels in which it circulates, and 
which is often connected with purpura haernorrhagica ; thirdly, from a 
local cause. 

First Variety. — In 49 cases, which I have collected from different 
writers, the haemorrhage occurred in 38 under the age of six days, in 5 
from six to ten days, and in 6 from ten to twenty days. Some authors 
cite cases which occurred at the age of several weeks, but haemorrhage 
into the intestines at so late a period cannot be due to any cause operating 



GASTRO-INTESTINAL HEMORRHAGE. 763 

at birth, and it is proper to consider such as examples of one of the other 
varieties. 

Passive congestion of the gastro-intestinal mucous membrane is not 
infrequent in the new-born. Billard speaks of twenty-five cases without 
haemorrhage which he has examined. This anatomical state of the mu- 
cous membrane of the intestines, whether occurring as part of a general 
plethora or being simply a local affection with no hyperemia of other 
parts, evidently requires only a certain increase and haemorrhage inevita- 
bly results. 

The cause of the abnormal congestion of the gastro-intestinal mucous 
membrane, so common in the new-born, has been referred by writers to 
the previous health of the parents, to circumstances attending the birth, 
especially to too speedy a ligature of the cord, to irritant matters in the 
intestines, to external violence, and to the two opposite extremes, namely, 
a plethoric and a feeble state. In my opinion, the chief cause, in many 
cases, is the tardy or incomplete establishment of the respiratory and cir- 
culatory functions, which gives rise to congestion in the cavities of the 
heart and in the lungs, and, consequently, in the capillaries of the sys- 
temic system. Evidently, this congestion is most intense in the full- 
blooded. Billard says of fifteen cases of intestinal haemorrhage which he 
examined, most of them were remarkable for the plethoric condition of 
their bodies and the general congestion of their integuments. Some, on 
the contrary, were pale and feeble, as is common after abundant haemor- 
rhage. 

In two infants who died soon after birth, and whose bodies I subse- 
quently examined, there was apparently a plethoric state, which rendered 
a fatal result more certain, if it did not, indeed, produce it. In one of 
these, in addition to intense general congestion, meningeal apoplexy had 
occurred, although the birth of the child had been easy. 

It is not difficult to understand in what way too speedy a ligature of the 
cord may be a cause of capillary congestion and haemorrhage. At the 
moment of birth, the uterus is contracted, the placenta compressed, and, 
if the cord be now tied, more blood remains in the vessels of the infant 
than if tied a little later. A little later, in consequence of the temporary 
cessation of uterine contractions, and the re-establishment of circulation 
in the infant, blood flows through the cord toward the placenta. The 
cord thus acts as a safety-valve to the circulation. Any accoucheur who 
will take pains to witness the effect on the cord of the return of circula- 
tion, will observe what I have stated. Too speedy a ligature of the cord 
would not, however, be sufficient in the majority of cases to produce that 
amount of plethora which would give rise to intestinal haemorrhage with- 
out other co-operating causes. 

Tardy or incomplete establishment of respiration and circulation, which 
gives rise to intestinal congestion and haemorrhage, may be due to disease 



764 GASTRO-INTESTINAL HEMORRHAGE. 

of the heart or lungs, as atelectasis or cyanosis, to feebleness of the infant, 
or to slow and difficult birth. In a large proportion of cases, however, 
the birth is easy. Thus, three of five patients with intestinal haemor- 
rhage, who were treated by M. G-endrin, were born of an easy labor, and 
the same was true of four infants observed by M. Kiwisch. 

Although gastro-intestinal haemorrhage in the new-born apparently 
results in certain instances from the conditions mentioned above, which 
produce congestion of the gastro-intestinal mucous surface, there are other 
cases in which the cause must be different. Dr. Silverman, of Breslau, 
has recently published the statistics of 42 cases (Jakr. fur Kinderh. , 
Sept., 187*7), 23 of which were fatal. In 25 of these the blood escaped 
both from the mouth and anus, in 10 from the anus alone, and in 7 from 
the mouth alone. The haemorrhage, in a majority of the cases, began in 
the second day after birth, but in 11 it began on the first day, and in all 
prior to the eighth. It is suggested that the haemorrhage, in certain in- 
stances at least, occurs from an ulcer in the gastro-intestinal surface, 
which is produced by an embolus in the umbilical vein, or its branches, or 
by suspension or incomplete establishment of the respiratory function in 
consequence of accidents of birth, atelectasis, etc. Ebstein, according to 
Silvermann, has demonstrated experimentally that the suspension of res- 
piration in animals produces congestion, extravasation of blood, ulcera- 
tion in the stomach. From the fcetal anatomy, it is evident that an em- 
bolus occurring in the umbilical vein near the liver, and extending into 
the branches of the vein, would be likely to cause congestion of the intes- 
tines by obstructing the portal circulation. 

Dr. Lederer states {Zeitung fur Kinderh. , Nov., 1877) that he has 
treated eight new-born infants for this disease, five of which died from the 
severe gastric and intestinal haemorrhage, accompanied also by umbilical 
haemorrhage. The age of the youngest was six hours. That of the old- 
est eleven days. They were all well developed ; of normal conforma- 
tion, and were nourished with breast-milk. In the three who were cured, 
the haemorrhage was arrested in twenty-four hours, but there was for & 
long time a tendency to intestinal catarrh. Dr. Lederer admits the obscu- 
rity of the cause, but does not think that it was an embolism in all the 
cases. 

The second variety of gastro-intestinal haemorrhage often occurs as a 
sequel of other and debilitating diseases. I have known it to occur as a 
sequel of measles, smallpox, scarlet fever, and in one case of typhoid 
fever. One of these patients, when apparently the period of danger was 
passed, began to lose blood from nearly all the mucous surfaces, from the 
nostrils and gums, as well as intestines, and the case, which but for the 
haemorrhage would doubtless have had a favorable issue, terminated fatally 
in less than a week. 

Patients with this variety of gastro-intestinal haemorrhage sometimes 



case. 765 

present the maculae of purpura, and commonly their aspect is pallid and 
cachectic. The following was a fatal case of hemorrhage occurring from 
the ileum, in a mild form of purpura hemorrhagica : 

Case. — An infant, eight months old, of healthy parentage, nursing, 
with no previous sickness, and fleshy, vomited a small quantity of blood 
on the 25th of March, 1865 ; soon after it passed a stool consisting of 
almost pure blood. On the following day five or six patches of purpura 
hemorrhagica were observed on the arms and legs. These maculae con- 
tinued till death. There was no more hsematemesis, but the stools, which 
were from two to four daily, consisted largely of blood. Death occurred 
from exhaustion on March 31st. 

Sectio Cadaver. — Head not examined ; thoracic organs healthy, but 
pale ; liver fatty ; stomach, upper part of small intestines, and entire 
colon of normal appearance, unless presenting a somewhat lighter color 
than the healthy intestine from deficiency of blood ; mucous membrane 
in the ileum to the extent of several inches, intensely injected without 
thickening. The blood had obviously escaped from this portion of the 
intestine, and a moderate amount of this fluid was found in the tube be- 
low the point of vascularity. This case is interesting not only on account 
of the development of purpura hemorrhagica, but the subsequent intes- 
tinal haemorrhage in a nursing child, apparently of healthy parentage, 
and without previous sickness. 

In our remarks on internal convulsions, the case is related of a scrofu- 
lous infant who, to all appearance in her ordinary health, suddenly be- 
came affected with intestinal haemorrhage in connection with external and 
internal convulsions. A point of interest in this case was the relation of 
the haemorrhage to the neurosis. In one of the three cases of intestinal 
haemorrhage described by West, there were also convulsions. In rare in- 
stances there is an hereditary haemorrhagic diathesis to which the haemor- 
rhage is attributable. In the New York Journal of Medicine and Sur- 
gery, July, 1840, Prof. Swett relates the history of a haemorrhagic family. 
Seventeen out of eighteen children of this family had died of haemor- 
rhages, and the survivor had had intestinal haemorrhage with epistaxis. 

In the third variety, among the local causes producing haemorrhage may 
be mentioned ulceration, as in typhoid fever, or in severe intestinal inflam- 
mation, the mechanical effect of solid substances, lumbrici, invagination, 
obstruction to the portal circulation, polypus of the rectum. Occasion- 
ally at the post-mortem examination of young infants I have found blood 
with mucus in the duodenum and jejunum, these portions of the intes- 
tines being at the same time intensely congested. In one case of pro- 
tracted entero-colitis occurring in the summer season, I found many 
small circular ulcers in the colon, nearly all containing points of extrav- 
asated blood. Such are the principal local causes of haemorrhage from 
the bowels. Ordinary colitis may also be considered a cause, although 
the amount of blood evacuated in this disease is commonly small. 

Of the three forms of intestinal haemorrhage described above, that 



766 GASTRO-INTESTINAL HEMORRHAGE. 

arising from local causes is most frequent, while that occurring from a 
purpuric or hemorrhagic diathesis is least frequent. In rare cases fatal 
intestinal haemorrhage may occur in the new-born, and the blood be 
retained in the intestine, or if passed it may so closely resemble the me- 
conium that its true nature is not discovered. Mr. Bednar relates the 
following case (Krankheiten der Neugebomen) : " On the eleventh day 
after birth the boy's skin (then of a pale yellow color) diminished in 
warmth, the impulse of the heart became dull and prolonged, the respira- 
tory murmur scarcely perceptible. The child lay almost motionless and 
slumbering. The day following the surface could scarcely be kept warm, 
and the little patient had to be aroused to suck. On the twentieth day 
after birth it died. The brain was found to be anaemic, the lungs pletho- 
ric, while blood was effused into the duodenum and stomach." 

Intestinal is more frequent than gastric haemorrhage, and the flow, ex- 
cept when produced by a local cause, is usually from the small intestines. 
The blood, unless it come from a point near the anus, as the rectum or 
descending colon, is commonly dark, and sometimes partially decom- 
posed, emitting an offensive odor. Admixture of the blood with the 
intestinal secretions prevents coagulation of the fibrin. 

G-astro-intestinal haemorrhage in itself produces few symptoms aside 
from the prostration which attends all haemorrhages. The disease with 
which it is associated may give rise to many and severe symptoms. 

Prognosis. — The result in the first and second varieties is much more 
unfavorable than in the third. Many new-born infants affected with gas- 
trointestinal haemorrhage die, but some recover. Billard attended fifteen 
fatal cases. It is probable, however, that death in the first variety is 
often due more to some coexisting lesion, than to the intestinal haemor- 
rhage. Meningeal apoplexy, and the incomplete establishment of the cir- 
culatory and respiratory functions, may both operate as direct causes of 
death in this variety. . 

In the second variety, also, a very guarded prognosis should be given ; 
so great a change in the circulatory system as to cause rupture of the 
capillaries, or transudation of blood in the ordinary course of the cir- 
culation, is a serious state. When this haemorrhage occurs as a sequel 
of the eruptive fevers, or in purpura haemorrhagica, the patient is more 
apt to die than recover. 

In the third form of intestinal haemorrhage, the result depends on the 
nature of the cause, whether it be susceptible of removal. The majority 
of cases in this variety recover. 

Treatment. — Billard recommends, as a means of preventing capillary 
congestion and haemorrhage in the new-born, to allow a little blood to 
escape from the umbilical cord before its ligation, if the establishment of 
respiration and circulation be difficult or incomplete. This relieves the 
hyperaemia of the internal organs and facilitates the flow of blood. After 



TREATMENT. 76T 

the commencement of internal haemorrhage and the appearance of bloody 
stools, the same may be done if plethora be indicated by the florid and 
robust appearance of the infant, and the cord be not too much shrivelled. 

The treatment, both therapeutic and regimenal, of intestinal haemor- 
rhage should vary according to the age and state of the infant, the pro- 
fuseness of the haemorrhage, and the nature of the cause. Perfect qui- 
etude, in the recumbent position, is requisite in all severe cases. Deriva- 
tion to the extremities should be procured in the young infant, by heated 
dry flannel or flannel wrung out of hot water ; in the older infant, by 
the same with the addition of mustard. The nursing infant should remain 
at the breast, being allowed, perhaps, in addition to the breast-milk, a lit- 
tle cool barley or gum-water. Spoon-fed infants should be given food of 
the blandest quality, in the liquid form and cool. This is the proper 
diet, whatever the age, in the commencement of the haemorrhage. If 
there be evidence of exhaustion, cool beef -tea, or essence, and alcoholic 
stimulants, are necessary. It has been advised, in certain forms of intes- 
tinal haemorrhage, to apply leeches over the abdomen or around the anus. 
This treatment would, in my opinion, rarely be useful, but, on the con- 
trary, in most cases, injurious. Haemorrhage from a mucous surface, 
when once established, will generally quickly relieve the local hyperaemia, 
and leeching, unless very cautiously employed, would promote the pros- 
tration, in which the real danger in this disease consists. On the other 
hand, moderate counter-irritation over the abdomen may be attended with 
real benefit as a derivative. 

The therapeutic treatment consists mainly in the use of astringents. 
Of the mineral astringents, acetate of lead and nitrate of silver have been 
used, but the liquor ferri subsulphatis is preferable to all other astringents 
in haemorrhage from the stomach and upper part of the small intestine, 
but it is believed to be decomposed in its passage through the intestine, 
so that it has less astringent or styptic effect in the lower bowel than gallic 
acid. It may be given to a child five years of age, in doses of five drops,, 
in sweetened water or in mucilage. 

Astringent enemata are sometimes useful. M. Rilliet treated a case 
which recovered with enemata, each containing twelve grains of extract of 
rhatany, a strong decoction of the same astringent being applied externally 
to the abdomen. M. Bouchut recommends " cold water externally to the 
abdomen, internally by the mouth, or by enemata frequently repeated. 
These enemata should be composed of two or three large spoonfuls only. 
They may be rendered more active with three grains of tannin, or with 
seven grains of the extract of rhatany, or seven grains of catechu, or, 
lastly, with one grain of nitrate of silver. In this latter case, a small 
glass syringe and distilled water must be used, to avoid the premature de- 
composition of the medicine." 

In the haemorrhage occurring in purpura, or after exhausting constitu- 



768 INTUSSUSCEPTION. 

tional diseases, tonics should be given in addition to astringents. In 
chronic inflammatory disease of the intestinal mucous membrane, attended 
by a vitiated secretion of the follicles, the haemorrhage may be best 
treated by turpentine. I have elsewhere related two cases of recovery by 
the use of this agent, in one of which (typhoid fever) lumbrici were ex- 
pelled. Ergot, from the contracting influence which it exerts on the 
arterioles, is also useful in many cases. It is especially useful in purpura 
hemorrhagica. 

If the haemorrhage be due to a local cause, as lumbrici or a rectal poly- 
pus, the treatment obviously should consist in the removal of this cause. 



CHAPTER XIII. 

INTUSSUSCEPTION. 

Intussusception, or the passage of one portion of intestine into an- 
other, has long been known as an occasional accident. Hippocrates, 
though debarred from the study of morbid anatomy, appears to have had 
u pretty clear idea of this lesion, and he suggested a mode of treatment 
which has been employed till the present time. 

Intussusception without Symptoms. 

This is not properly a disease. It consists in a displacement without 
any other anatomical change. There is, therefore, no obstruction, in- 
flammation, or even congestion present, and no symptoms. This form of 
invagination might ordinarily be reduced by the normal peristaltic and 
vermicular movements of the intestine. 

Invagination of a portion of the small intestine into the part immedi- 
ately below it is often observed at the post-mortem examination of young 
infants, who had presented no symptoms due to the displacement. The 
invaginated mass is usually from half an inch to two inches in length, 
and, as a rule, this accident is multiple. There may be ten or more dis- 
tinct intussusceptions, at distances of a few inches from each other. The 
simple displacement is believed to occur ordinarily at or a short time prior 
to the moment of dissolution. It has been supposed to be most frequent 
in those who have died of cerebral or spasmodic diseases, but its occur- 
rence is not unusual in other pathological states. I have often found it at 
the post-mortem examination of infants who have had subacute or chronic 
entero- colitis. Hevin states that he has seen it at the Salpetriere over 
three hundred times. Billard has seen it especially in infants who have 
been subject to constipation. Any irritant, mechanical or other, which 



INTUSSUSCEPTION WITH SYMPTOMS. 769 

disturbs the regular movements of the intestines, doubtless may produce 
it. It has been caused in the rabbit by irritating the anus. 

It is not improbable that simple intussusception occasionally occurs 
temporarily in children whose health remains good, when the regular 
movements of their intestines are disturbed by irritating ingesta or other 
causes. This form of displacement never takes place in the large intes- 
tine. Its usual seat is the lower part of the jejunum, and upper part of 
the ileum. Since it possesses little interest as regards pathology, and none 
whatever as regards symptomatology and therapeutics, it may be ignored 
in our description of intussusception. 

Intussusception with Symptoms. 

Intussusception, or invagination, is one of the most painful and danger- 
ous of human maladies, but fortunately is not very frequent. I have the 
records of fifty-two cases occurring in children, from which the facts 
contained in this article are chiefly derived. The patients were under 
the age of twelve years. 

Previous Health. — In thirty-four of the fifty-two cases, the state of 
the health previously to the invagination was recorded. From the follow- 
ing table it is seen that half, or seventeen, were previously well, the re- 
maining half suffering from some disease or derangement : 

Previous Health. 



Age. Good. Disease or Derangement. 

One year or under, ... 15 8 

Over one year, . .2 9 

17 17 

MM. Rilliet and Barthez, whose views in reference to intussusception 
are derived from the examination of the records of twenty-five cases, state 
that the previous health is ordinarily good, and the intussusception is, 
therefore, primary. Their remark, according to the above statistics, is 
seen to be correct as regards patients under the age of one year, but in- 
correct for those over that age. 

Most of the seventeen who had previous ill-health had diarrhoea, dysen- 
tery, or constipation, or diarrhoea alternating with constipation. Of 
those otherwise affected, one had thread- worms, two obscure abdominal 
pains, one nausea and vomiting, and one, whose age was four months, had 
had symptoms of invagination when ten weeks old, which soon passed 
off. It is seen that the pre-existing affections were ordinarily such as 
would be likely to accelerate the movements of the intestines and at the 
same time render them irregular. 

Causes. — The above statistics, therefore, show that intussusception is 
often preceded by disease or functional derangement of the intestines. 
49 



770 INTUSSUSCEPTION. 

The two opposite conditions, namely, constipation and the diarrhoeal 
maladies, so often precede the displacement that they must be regarded as 
common causes. Another probable cause is intestinal worms, which, 
by their mechanical action, stimulate the intestines. They were present 
in three of the fifty-two patients, though two of the three seemed well till 
the occurrence of the intussusception, bat the other patient had com- 
plained of irritation at the anus, and ascarides had been found on examina- 
tion. 

The use of irritating and indigestible food is an occasional cause. 
Thus, some who have had intussusception have been in the habit of tak- 
ing fruits, candies, and pastries freely. Such ingesta may be an immedi- 
ate cause by their irritating effect, or a remote cause giving rise to diar- 
rhoea, which, in turn, produces intussusception. 

Sex is a predisposing cause, since male patients are largely in excess. 
Of the twenty -five cases collated by Rilliet and Barthez, all but three were 
boys. In our own collection, the sex of thirty-four of the patients was 
recorded, and of these twenty-three were boys. 

In rare instances external violence is the apparent exciting cause. One 
patient received a severe contusion of the abdomen two years before death, 
and from this time continued to complain at intervals of pain in the bow- 
els. One writer also mentions the case of a child nine years old who 
received a blow from a comrade at school, and from this time had alter- 
nately diarrhoea and constipation till the invagination commenced. Ril- 
liet and Barthez also relate the case of two children who were taken sud- 
denly with invagination when their parents were tossing them in their 
arms. 

Age. — Of the fifty -two cases embraced in our statistics, the ages were 
as follows : 

3 were 3 months old. 1 was 10 months old. 

12 " 4 .«■ " 1 " 11 " 

• 3 " 5 " 1 " 12 " 

5 " 6 2 were from 1 to 2 years old. 

1 was 7 " 8 " " 2 " 5 " " 

1 " 8 " 8 " " 5 " 12 " " 

3 were 9 " " 3 not given. 

Therefore, no cases occurred under the age of three months, 23 cases were 
between the ages of three and six months, or nearly one half of the entire 
number, 8 between the ages of six months and one year, and only 18 be- 
tween the ages of one year and twelve. These statistics correspond, in 
the main, with those of Rilliet and Barthez, in whose collection of 25 
cases no one was under the age of four months. Leichtenstern says : 
" Half of all invaginations, according to my statistics of four hundred 
and seventy-three cases, occur during the first ten years. The first year 



INTUSSUSCEPTION IN SMALL INTESTINES. 771 

after the third month is remarkable for a special frequency — one fourth 
of all intussusceptions." (Ziemssen's Encyclop.) 

The great liability to intussusception in infancy is due partly to the 
anatomical character of the intestine in this period of life, and partly, 
doubtless, to the fact that there are more frequent irregularities in the in- 
testinal movements than in older children. In the infant the walls of the 
intestines are thin, the mucous and muscular coats and the connective tis- 
sue being much less developed than in those that are older ; the mesentery 
and meso-colon have also greater depth as compared with the same in 
other periods of life, except the meso-colon at the points where it passes 
over the kidneys, in which places it is very short, or even in some cases 
nearly absent. Moreover, the space occupied by the large intestine, in 
which part of the digestive tube intussusception commonly occurs, is 
much shorter relatively to the length of the intestine than in those that 
are older. In about thirty measurements which I have made of the 
length of the large intestine and the space occupied by it, the latter was 
found, in the average, about one third that of the former, which, of 
course, necessitates doubling of the intestine on itself. These peculiari- 
ties of structure in the infant obviously favor the occurrence of intussus- 
ception. 

Seat and Pathological Anatomy. — While intussusception occurring 
without symptoms is usually multiple, that form which occurs with symp- 
toms is ordinarily single. Two exceptional cases which I observed will be 
presently related. In one of the cases embraced in the statistics an in- 
vagination occurred with symptoms, and coexisting with it was another 
in the small intestines apparently without symptoms, and quickly reduced 
by handling. 

While intussusception without symptoms occurs in the small intestine, 
the seat of intussusception with symptoms is, with occasional exceptions, 
the colon. The colon constitutes the entire invaginated mass, or else, 
and more frequently, it forms the exterior, while the incarcerated portion 
consists wholly or in part of the ileum. 

Intussusception in the Small Intestines. 

Bouchut says : " M. Rilliet states, in a recent treatise, that in infancy 
the intestinal invagination is always accomplished at the expense of the 
large intestine, and that there is never invagination of the small intestine. 
This is incorrect. I have observed the small intestine invaginated in the 
adjacent inferior part. Taylor has reported a case of this kind in a child 
twenty months old, who died after an attack of acute peritonitis. M. 
Marage has seen another case in a child thirteen months old, who recov- 
ered after having voided the invaginated portion furnished with two of 
those diverticula so frequent in the small intestine of the foetus." 

But, from all that appears, the case reported by M. Marage may have 



772 INTUSSUSCEPTION. 

been, and probably was, an example of the common form of intussuscep- 
tion, namely, of the ileum into the colon. In Mr. Taylor's case the in- 
vagination was really of the ileum into the colon, although a small portion 
of the ileum next to the valve had not been inverted, so that it constituted 
a little of the exterior of the mass. 

Nevertheless, Bouchut is correct in stating that irreducible and fatal in- 
tussusception may occur in the small intestines. Probably the displace- 
ment is at first of the simple variety, but, continuing and increasing in 
extent, its return becomes impossible. The positive statement of so great 
an authority as M. Rilliet, that intussusception with symptoms does not 
occur in the small intestines, justifies the publication of the following cases, 
which establish the fact that there are instances, though not frequent, in 
which the displacement does have this location : 

Case I. — Male. This patient's health had been uniformly good, and 
nothing unusual was observed in his condition till the age of four and a 
half months, when he became restless, as if in almost constant pain, with 
occasional exacerbations. Castor oil was prescribed, which operated 
freely, and then the following mixture : 

]£. Magnes. calcinat., 3j ; 

Tinct. opii camphorat., 3 ij ; 
Tinct. asafcet., 3 ss ; 
Aq. anisi, |j. Misce. 
Dose, ten to twenty drops, repeated according to the pain. 

These remedies failed to give relief, as did also chloroform given in 
doses of two drops. After two or three days, another set of symptoms 
arose, those characteristic of pneumonitis, namely, hurried respiration, 
accelerated pulse, short suppressed cough, and expiratory moan. He 
was treated with the oiled silk jacket, and mild counter-irritation, and 
took an expectorant mixture containing carbonate of ammonium. In a few 
days the pulmonary disease was evidently subsiding, but the pain in the 
abdomen, with occasional exacerbations, continued. His countenance 
was pallid, and bore an expression of suffering. There was no distension 
or tenderness of abdomen, and no abdominal tumor. He took little 
nutriment, and seldom vomited. In the last part of his sickness the de- 
jections were scanty, and the last three days his stools consisted mainly 
of mucus and a little blood. The pain seemed to be growing less, when 
he was seized with convulsions, and died the same day, precisely two 
weeks from the commencement of his sickness. 

Sectio Cadaver. — Head not examined ; body slightly emaciated ; mu- 
cous membrane of trachea and bronchial tubes vascular ; posterior por- 
tion of the lower lobe of each lung solid, of greater specific gravity than 
water, and allowing only partial inflation ; it was in the second stage of 
pneumonitis. Stomach, duodenum, jejunum, healthy. In the upper 
part of the ileum was an intussusception two thirds of an inch long, pre- 
senting no trace of inflammation, either within or around it, and its vas- 
cularity, when it was examined externally, did not seem notably in- 
creased. Above the intussusception the intestine was empty ; below it, 
and chiefly in the small intestine, was a dark-colored substance evidently 
blood, and giving in a few hours the offensive odor of decaying animal 



INTUSSUSCEPTION IN SMALL INTESTINES. 773 

matter. There was a passage through the intussusception, at least two or 
three lines in diameter, as shown by a probe. The intussusception sus- 
tained the weight of sixteen inches of the -intestine,, and it would appa- 
rently have sustained considerably more. The remaining organs were 
healthy. 

Case II. — F. S., a female infant, four months old, was treated at the 
New York Infant Asylum in June and July, 1865, for entero-colitis, the 

Fig. 26. 




usual epidemic of the summer season. The following records show the 
state of the bowels immediately before her death : 

June 29th. Has five or six stools daily. 30th. Two stools in twenty- 
four hours. July 1st. Had two stools since the last record ; no vomit- 
ing. 3d. Four stools in last twenty-four hours. 4th. The diarrhoea 
continues as before ; the stools about four daily. On the 6th of July she 
died. 

Her pulse during the time in which these records were taken generally 
numbered about 128 per minute. She was much emaciated, and the 
day before death she frequently struck her head with her hand. The 
medicines employed were mainly alkalies and astringents. 

Sectio Cadaver. — Parietal bones united ; some serous effusion over the 
convolutions of the brain, under the arachnoid ; occipital bone de- 
pressed ; commencing at a point about two feet below the stomach were 
four intussusceptions two or three inches from each other. The invagi- 
nated masses were from one to one and a half inch in length, and three of 
them were found to be very vascular in their interior. Above, between, 
and immediately below the intussusceptions the intestine was healthy. 
One of the invaginations was tested by weight, and was found to sustain 
one and a half foot of intestine, and would have sustained more. Water 
poured above these intussusceptions escaped through them very slowly ; 
no fibrinous exudation ; descending colon vascular and thickened, and 
solitary glands enlarged. 



774 INTUSSUSCEPTION. 

The irreducible character of the intussusceptions in the above cases was 
shown by the fact that they sustained weights which doubtless produced 
greater traction than that exerted by the intestine in its normal action. 
That the displacement existed prior to the moment of death was shown 
by the symptoms in one of the cases and by the anatomical changes in 
both. In one the capillaries of the incarcerated mass were ruptured dur- 
ing the last days of life, so as to produce sanguineous stools ; while in the 
other there was intense congestion of the invaginated mucous membrane, 
while that portion of this membrane which was adjacent but not engaged 
was healthy. 

In both patients the symptoms were less severe than in ordinary cases, 
and they came on more gradually, for the invaginated intestine was not 
completely closed, so that it allowed the passage of faecal matter in one till 
the close of life, and in the other till near its close. At both of the 
autopsies water poured into the intestines above the invaginations passed 
slowly through them. 

Intussusception in the small intestines in the infant, commencing as the 
simple form, may become irreducible, and yet remaining pervious may 
continue for weeks without giving rise to severe or dangerous symptoms. 
The following case was an example of this : 

Case. — Male child, died at the age of nineteen months, the last eleven 
of which he was under observation. The mother states that he had 
never been well since the age of ODe month, and that there had been lit- 
tle variation in the symptoms of his disease. During the period in which 
he was under observation, he was ordinarily fretful, and frequently 
seemed to be in considerable pain. His stomach through this whole 
time was so irritable that he rarely took more than three or four 
spoonfuls of nutriment without vomiting. There was usually more or less 
diarrhoea, but no tenderness or distension of abdomen. He became 
slowly but gradually more emaciated, and finally died in a state of ex- 
treme emaciation and exhaustion. He had no convulsions, and was 
conscious to the last. 

Sectio Cadaver. — Brain not examined ; lungs healthy, except a circum- 
scribed portion which was inflamed at the summit of the right lung ; 
liver small and almost destitute of oily matter, as shown by the micro- 
scope. In the jejunum, about two feet below the stomach, was an intus- 
susception two inches long, the intestine forming which seemed to have 
undergone no structural change. Above the intussusception the intestine 
was of small calibre, and entirely empty and pale ; below the intussuscep- 
tion the intestine was somewhat larger than above, but it seemed quite 
healthy. The invagination was sufficiently pervious to allow water to 
pass through it, and it readily sustained the weight of two feet of intes- 
tine. From eight to ten inches below this intussusception there was an- 
other, which was immediately drawn out the moment the intestine was 
disturbed. The other abdominal viscera were healthy. 

There is uncertainty as to the duration of intussusception in the above 
case, but the symptoms indicated that it existed a considerable time prior 



INTUSSUSCEPTION IN LARGE INTESTINES. 775 

to death. There was no strangulation, nor indeed any appreciable ana- 
tomical alteration in the coats of the intestine, but the fact that the in- 
vaginated mass sustained two feet of intestine, and required considerable 
traction for its reduction, shows that it was not a case of simple displace- 
ment occurring at the moment of death and without symptoms, but was 
an example of the variety with symptoms. 

Intussusception in Large Intestines. 

In most cases of intussusception occurring in infancy and childhood, 
the ileum is invaginated in the colon, or the first part of the colon is in- 
vaginated in the part succeeding it. Intussusception not infrequently be- 
gins in the prolapse of the ileum through the ileo-caecal valve, in the same 
way that prolapse of the rectum occurs through the sphincter ani. If 
death take place early, only a small portion of the ileum may have passed 
the valve. If the case be protracted, the tenesmus brings down more and 
more of the ileum, with its accompanying mesentery. The constriction 
of the valve, which acts as a ligature, soon prevents the further descent of 
the ileum ; and, the tenesmus continuing, the next step in the displace- 
ment is the inversion of the caput coli, which is drawn into the colon by 
the descending mass, and, unless the case terminate by sloughing or 
death, the ascending and transverse portions of the colon are successively 
invaginated. The records show that intussusception occurs as above 
stated in a large proportion of cases. In one case, among those which I 
have collated, the invagination began a few inches above the valve, so 
that the ileum constituted a small portion of the exterior of the mass. 
Occasionally the caecum is the part primarily inverted and invaginated, 
and, descending along the colon, it draws after it the ileum, which sus- 
tains its natural relation to the ileo-caecal valve. When this occurs the 
caecum is found at the lower end of the mass, and two orifices are ob- 
served, one leading through the valve, and the other into the appendix 
vermiformis. These two forms of invagination — that in which the ileum, 
passing through the ileo-caecal valve, successively inverts and draws after 
it the caput coli and the divisions of the colon ; and that in which the 
caput coli is primarily invaginated, and descending along the large intes- 
tines, inverts the latter, and draws after it the ileum — constitute the vast 
majority of cases of this disease in the first years of life. 

I have notes of 45 fatal cases occurring under the age of twelve years, 
in which the portion of intestine first displaced is recorded. In four of 
these the displacement was entirely in the small intestine, involving in no 
way the colon ; in 38 cases it commenced either by prolapse of the ileum 
through the ileo-caecal valve, or by inversion of the caecum into the 
ascending colon, there being perhaps not much difference in the relative 
frequency of these two modes ; in one case the invagination was confined 



776 INTUSSUSCEPTION. 

to a segment of the transverse colon, in another to a segment of the de- 
scending colon, and in the remaining case to the lower part of the de- 
scending colon and the upper part of the rectum. In three instances the 
invaginated mass itself became invaginated, producing an intussusception 
of great thickness, and necessarily fatal. 

As we have seen in regard to intussusception in the small intestines, 
so that occurring in the large intestine may be attended by so little con- 
striction of the incarcerated portion that it remains pervious, though with 
diminished calibre. In such a case life may be protracted for weeks or 
even months, without reduction of the displacement or any material 
change in it, the passage of faecal matter being sufficiently free for the 
maintenance of life. Death finally occurs in a state of exhaustion. Thus 
in one instance a child, four months old, lived six weeks after the symp- 
toms of invagination commenced, and seventeen days " with a portion of 
the bowel protruding from the anus. ' ' It was found at the post-mortem 
3xamination that part of the ileum had descended through the entire 
colon, and had remained pervious. In a case related by Dr. Worthing- 
ton in the Amer. Jour, of Med. Sci. for January, 1849, symptoms of 
intussusception were present for seven months before death, and during^ 
the last six weeks of life the invaginated intestine protruded frequently 
from the anus, and was replaced by the mother. In this case " the 
csecuni was inverted, and descending through the colon to the lower por- 
tion of the rectum, carried with it the ileum and the entire colon, except 
the last ten or twelve inches. ' ' In another case the symptoms indicated 
a continuance of the disease for three, if not eight, months. But such 
cases are exceptional. Ordinarily as the intestine becomes invaginated, its- 
mesentery or meso-colon is also invaginated, and its veins compressed. 
The pathological state of the incarcerated mass soon becomes that of in- 
tense congestion. In infants, usually in a few hours, so great is the dis- 
tension of the capillaries that they give way, blood escapes into the intes- 
tine, and passes from the bowels in scanty motions. On examining the 
invaginated intestine after death, if gangrene have not occurred, it is 
found of a uniformly intense red color, sometimes resembling to the naked 
eye a long and firm clot of blood. In those who die early no traces 
of inflammation are seen, but in more protracted cases the attrition be- 
tween the serous surfaces excites local peritonitis. In none of the fifty-two 
cases which I have collated in which post-mortem examinations were 
made, did the inflammation extend more than a few lines beyond the in- 
vagination. Usually the intestine forming the exterior of the invaginated 
mass is much drawn together or puckered. In one case treated by my- 
self, the entire large intestine which formed the exterior of the mass was 
compressed within a space of six inches or less, since about twelve inches 
of the ileum, doubled on itself, lay within the entire colon and protruded 
from the anus, the only part of the large intestine which was inverted 



SYMPTOMS. 777 

being the caput coli. In one case six or seven inches of the ileum, which 
formed a portion of the exterior of the mass, were compressed within the 
space of one inch. 

The abdomen, at first of natural fulness and soft, usually becomes more 
and more distended till the close of life ; but in cases of much vomiting 
the distension is moderate. This fulness is due to gas and faecal accumu- 
lation above the invagination. The portion of intestine below the dis- 
placement is ordinarily empty, except that in the infant it commonly con- 
tains mucus, mixed with more or less blood, which has escaped from the 
capillaries of the strangulated mass. 

There are few anatomical changes in this disease, which do not arise 
directly from the intussusception, and are, therefore, located either within 
the mass or in its immediate vicinity. In those who recover by the pro- 
cess of sloughing, the cicatricial contraction may give rise to symptoms 
and lesions of greater or less gravity. Thus the late Sir James Y. Simp- 
son examined a child aged 9 years, who recovered with loss of ten inches 
of intestine, and at the meeting of the Medical Society, before which the 
specimen was presented, remarked that there was unusual distension of 
the cutaneous veins of the patient, due probably to such compressions of 
the ascending vena cava by the cicatrix, that the venous circulation was 
obstructed. [Trans. Medico- Chir. Soc, Edin.) In the London Lancet 
for 1854, Mr. Charles King relates the case of a child aged 6 years, who, 
on the eleventh day of the disease, voided the caecum and a part of the 
colon. Two days subsequently pulsation ceased in the left leg, and all 
that part below the patella became gangrenous. The patient gradually 
recovered with loss of the leg. The cause of this unfortunate sequela was 
doubtless compression from the cicatricial contraction of the artery which 
supplied the leg, and probably the formation of a thrombus. In the 
Lond. Med. and Phys. Jour, for December 18, 1823, Dr. F. Bush relates 
a case in which he was enabled to observe the extent and appearance of 
the cicatrix. The patient, aged twelve years, discharged from the bowels 
fifteen to eighteen inches of the ileum on the eighth day of the intussus- 
ception, after which convalescence was rapid. Fourteen weeks later the 
child died from typhus fever, and at the autopsy " traces of the diseased 
bowels were visible by a contraction and puckering where the slough 
had taken place, and the parts united." But fortunately in most in- 
stances when the intestine sloughs and the child survives, no serious or 
pennanent injury results from the cicatrization. The cicatrix stretches 
little by little, and accommodates itself to the surrounding parts. 

Symptoms. — The symptoms vary according to the age of the patient 
and the degree of strangulation. Pain in the abdomen, usually paroxys- 
mal, is among the first, and is one of the most conspicuous symptoms. 
It is often severe, resembling the pain of hernia, and abating only with 
the failing strength of the child. After the first few days, if inflammation 



778 INTUSSUSCEPTION. 

arise, the pain is continuous, though more severe in paroxysm. At first 
pressure upon the abdomen is tolerated, but afterward there is tender- 
ness. This is due to the inflammation, which occurs in and around the 
invaginated mass, and it is, therefore, confined to the part of the abdo- 
men in which the tumor lies. At this point also the abdomen is more 
full than elsewhere, and not infrequently the physician can feel the in- 
vaginated mass and detect its exact location, and approximately its extent. 
Sometimes, at an early period as well as late, cerebral symptoms occur, as 
in a case related by Dr. Coggswell in the London Lancet for July, 1853, 
which terminated in convulsions and death on the second day. Convul- 
sions are, however, comparatively rare, and the mind is generally clear till 
the last moment. In infants the countenance, in the intervals of pain, in 
the first stages of the complaint, is often placid and not indicative of any 
serious disease, but in older patients constant and severe local symptoms, 
referable to the intussusception, commence early. At an advanced period, 
whatever the age, the countenance becomes anxious and haggard, the eyes 
hollow or sunken, the body loses its plumpness, and, if the case be pro- 
tracted, becomes emaciated. 

Vomiting is rarely absent ; in thirty-nine out of forty-seven cases it is 
stated to have been present, in seven cases there is no record of this symp- 
tom, while it is recorded absent in only one case ; but in this case, the 
records of which are very meagre, death occurred on the second day. 
The vomiting becomes stercoraceous in a few days, and it ordinarily con- 
tinues with greater or less frequency till the period of collapse. It re- 
lieves partially the distension. 

The appetite is impaired and often entirely lost. Infants at the breast 
commonly nurse, however, for several days, probably from thirst rather 
than hunger. 

In most patients one natural evacuation occurs from the bowels after the 
intussusception commences, and then obstinate constipation succeeds. 
This evacuation consists of the excrementitious matter below the invagina- 
tion. In children under the age of one year, scanty motions of blood 
mixed with mucus begin to occur in a few hours. In twenty-seven chil- 
dren under this age I find that twenty-four had such evacuations, occur- 
ring in most of them several times in the course of the day ; in two of 
the twenty-seven there is no record of this symptom, but in the remaining 
case it is stated to have been absent. Scanty evacuations of blood un- 
mixed with faecal matter have been considered pathognomonic of intussus- 
ception in the infant, and we see the ground for such belief, but in ex- 
ceptional instances the invaginated mass is partly pervious, and although 
the dejections may contain blood, they are also excrementitious. In our 
collection of cases are three examples of this in infants under the age of one 
year. One has already been referred to. In this case there was the rare 
anomaly of so large an opening through the ileo-csecal valve, as to allow 



DIAGNOSIS. 779 

not only prolapse and descent of the ileum through the entire colon, so 
as to protrude six inches from the anus, but also faecal passages through it 
daily. 

In children above the age of one year, the capillaries of the invaginated 
intestine are not so frequently ruptured as under this age, and sanguineous 
evacuations are therefore less common. I have records of nineteen cases 
between the ages of one year and twelve, in only six of which it is stated 
that there were bloody motions, and in these the blood was not passed 
frequently, nor even in some cases daily, as in infants, nor in so pure a 
state, unless in two cases, the records of which are not explicit on this 
point. Two of these six patients passed moderate bloody evacuations 
after protracted periods of constipation, one had faecal discharges with 
the blood through the entire sickness, and in one blood was passed at 
first, but finally the stools were entirely faecal. 

In those above the age of one year, obstinate constipation was ordi- 
narily present, no dejections, whether bloody or faecal, occurring for 
several days, but there were a few exceptions. In three cases the bowels 
were relaxed. The ileum, in these three, had descended through the 
entire colon, or the larger part of the colon, and being pervious, the faeces 
escaped from the anus without detention in the large intestine, or with 
detention only in its lower portion, and were therefore liquid. 

Tenesmus is another symptom. It is not always present, but in a large 
proportion of cases, even when the invagination is in the upper part of 
the large intestine, it is a frequent and distressing symptom. It often 
does not commence till there is a considerable amount of displacement, 
and it ceases when the strength is much reduced. 

The temperature of the surface is normal in the commencement of in- 
tussusception ; but finally, as febrile reaction comes on symptomatic of 
the inflammation, it rises and continues above the healthy standard till the 
intestine sloughs, or till the stage of collapse occurs which ushers in 
death. The pulse, especially in the infant, is tranquil at first, but, what- 
ever the age, it soon becomes accelerated from the paroxysms of pain, and 
subsequently from the inflammation which occurs in the invaginated mass. 
There is no disturbance of respiration, except that it is somewhat hurried 
from the fever, and from the pain felt in advanced cases on full inspira- 
tion. 

It will be seen that the symptoms vary in certain particulars, under the 
age of one year, from those occurring over that age, but differences in the 
symptoms depend more on the degree of invagination and constriction, 
than on the a^e and exact location of the disease. 

Diagnosis. — The diagnosis of intussusception is not, in general, diffi- 
cult, expect at its commencement. When the inversion has reached that 
degree at which obstruction occurs, the symptoms are, in most cases, such 
that the disease can be readily diagnosticated. In the cases whose 



780 



INTUSSUSCEPTION. 



records I have collated a correct diagnosis was, with few exceptions, 
made, and at an early period. In the infant, the disease for which intus- 
susception is most frequently mistaken is dysentery, on account of the 
tenesmus and the muco-sanguineous stools. In certain of the reported 
cases this mistake was not rectified until it was ascertained that purgatives 
produced no faecal evacuations. 

The symptoms which are commonly present, and which indicate the 
nature of the disease, are obstinate constipation, vomiting, paroxysmal 
pain referred to the seat of the disease, and tenesmus. In the infant, 
also, scanty evacuations from the bowels of mucus and blood, or of pure 
blood, is, as we have seen, an important diagnostic sign. It should be 
borne in mind, however, that in exceptional cases the displaced bowel 
may remain pervious, and the usual symptoms which possess diagnostic 
value therefore be absent. There may be no vomiting or tenesmus, and 
diarrhoea may even occur in place of constipation, as in the cases re- 
lated above. As an aid to diagnosis, it should be stated that whatever 
the age of the child affected with intussusception, clysters are often ad- 
ministered with difficulty, and are quickly and forcibly returned, on ac- 
count of the resistance opposed by the invaginated mass. We have 
stated above that the seat and even extent of displacement can be ascer- 
tained in a large proportion of cases by digital examination of the abdomi- 
nal walls. The tumor can be felt hard, elongated, and tender on pres- 
sure, so that the diagnosis is clear. If the invagination have extended 
to the lower part of the large intestine, it can usually be discovered by an 
examination per rectum. 

Duration. — In the following table, the duration of the intussusception 
in forty-nine cases is given, as nearly as it can be ascertained from the 
records : 



2 died the 1st day. 


1 died the 8th day. 


6 " " 2d " 


1 " " 10th " 


14 " " 3d "_. 


1 " " 14th " 


2 " " 4th " 


1 lived nearly a week. 


5 " " 5th " 


1 "6 weeks. 


2 " " 6th " 


3, time of death not given 


2 " " 7th " 


7 recovered. 



1 lived over a week. 



In two of the three cases in which the duration is not stated, the 
patients lived much longer than the usual period. One of these two, a 
girl of six years, having eaten raw carrots, was seized with pain in the 
abdomen, which lasted eight months, when she died. During the last 
three months she passed mucus and blood. In this case the caecum had 
descended to the anus, drawing with it the ileum, which remained pervi- 
ous. The symptoms indicated the continuance of the invagination for 
three months if not eight. The other patient was a boy, aged 3 years 



PROGNOSIS. 781 

and 4 months, who complained of pain in the abdomen for many months, 
and occasionally vomited. During the last six weeks of his life, all the 
phenomena of invagination were present. In this case also, the inverted 
caput coli had descended along the entire length of the colon, and it lay 
at the autopsy in the rectum. 

In West's Treatise on Diseases of Children (fifth edition, 1866, page 
504), it is stated that death in this complaint always occurs within a 
week. The above statistics, however, show that there are exceptions to 
this statement, although a large majority do die within the first seven 
days. In thirty-three of the cases embraced in my statistics death oc- 
curred within the first week, and in no fatal case in which strangulation 
was complete was life prolonged beyond the eighth day. In these cases 
of complete strangulation the average duration was 3.7 days, and the larg- 
est number of deaths occurred on the third day. Death on the first day 
is rare, but it occurred in two instances. When so early it is often, if 
not generally, in convulsions and coma. 

Prognosis. — Intussusception is in its nature so grave an accident that 
the physician called to a case should always explain its gravity to the 
friends. But, while death is the common result, there are three different 
modes of termination in which life is preserved. First, the reduction of 
the incarcerated intestine, with immediate relief. There can be no doubt 
that it is possible for intussusception, when recent, to be reduced by the 
unaided action of the bowels, in the same way as the common, simple in- 
tussusception in the jejunum and ileum, or as hernia is reduced, through 
the vermicular action of the intestines, for sometimes, as in Dr. Coggs- 
well's case (London Lancet, July, 1853), the patients at some previous time 
have experienced the same symptoms as those which accompanied the at- 
tack, and which subsiding, they remained for a time in perfect health. 
This termination is probably rare, if the symptoms be sufficiently marked 
to necessitate treatment. Again, the intussusception may be cured by 
early and well-applied treatment. The physician often succeeds in reduc- 
ing the displaced intestine, even if the intussusception be in the upper part 
of the colon, if he be called sufficiently early, aad employ the proper 
measures. 

A second mode of favorable termination is alluded to by certain for- 
eign writers. The intussusception continues for a considerable period 
with the characteristic symptoms, and then, as Bouchut expresses it, 
" the vomitings gradually cease, the intestinal haemorrhage disappears, 
the strength returns, and the health becomes restored without the expul- 
sion of fragments of the intestine." What changes the displaced intes- 
tine undergoes in these protracted cases, which gradually recover without 
sloughing, have not been clearly ascertained, although they have been the 
subject of conjecture. According to Rilliet, a large proportion of favor- 
able cases terminate in this manner. It does not appear, however, from 



782 INTUSSUSCEPTION. 

the statistics which I have collected, that this is a common mode of 
recovery. The clinical history of intussusception establishes the fact that 
in a large majority of protracted cases there is either death or the third 
mode of favorable termination, namely, by sloughing. 

But we cannot reasonably expect recovery in young children through 
sloughing and the expulsion of the intestine ; since few have the requisite 
strength for so tedious and exhaustive a process. The youngest child 
that recovered in this way, so far as I have been able to ascertain, was an 
infant thirteen months old, whose case was reported by M. Marage. 
With the exception of this case, the youngest was a boy, aged five years. 
The older the child, the greater, of course, the power of endurance, and 
the better the prospect of recovery. Of the fifty-two cases whose records 
I have collated, seven recovered by the sloughing and expulsion of the 
mass. These children were of the ages of five, six, six, nine, eleven, 
twelve, and twelve years. The separation of the invaginated mass oc- 
curred in six of these between the sixth and twelfth days, with an average 
of nine and a half days. In the remaining case the time is not given. If, 
then, the patient can be carried through the first week without too much 
exhaustion, we may each day look for the discharge of the slough, the re- 
opening of the bowels, and ultimate recovery. 

But in those cases in which the intussusception remains open, so as to 
allow the passage of faecal matter, recovery is improbable unless the dis- 
placement be diagnosticated early and properly treated. If the intussus- 
ception continue, it becomes greater and greater from the absence of 
strangulation. Without inflammation and with little or no congestion of 
the displaced portion, and without the severe symptoms which occur in 
ordinary cases, the patient wastes away, having irregular evacuations and 
more or less abdominal pain, and finally dies in a state of emaciation and 
weakness. In the early stage of this form of displacement it is not im- 
probable that injections or inflation, employed with sufficient force, will 
give relief, but, if the early period pass without such treatment, cure is 
impossible by the ordinary methods. It is in such instances especially, 
to wit, those in which the displacement occurs without strangulation or in- 
flammation, and in which faecal matter passes through the displaced mass 
more or less freely, that laparotomy is justifiable, and is likely to give re- 
lief, when injections and inflation have been employed in vain. Jona- 
than Hutchinson's successful performance of this operation in a child of 
two years, who had this kind of displacement, is known to most readers. 
(See London Lancet, November 22, 1873.) 

The prognosis is most favorable when the displacement occurs in the 
lower part of the large intestine, for its reduction is then comparatively 
easy. An interesting case of this kind was observed and treated by Drs. 
O'Dwyer, Reid, and myself, in the New York Foundling Asylum, in 
1875. The child was a female, aged two years, and had had previous 



TREATMENT. 783 

good health. The invaginated mass protruded like a prolapse, about 
four inches outside of the anus. It was cold, considerable haemorrhage 
had occurred from it, and the infant seemed in collapse. When the mass 
was returned so far as it could be carried within the pelvis, by the index 
finger, the lower end of it could still be felt like an os uteri. It pro- 
truded four or five times within twenty-four hours, but, by replacement 
so far as possible with the fingers, and the use of simple water injections, 
with the hips elevated, it was finally permanently reduced, and, with the 
use of stimulants, she soon fully recovered. 

Mode of Death. — This is different in different cases. It sometimes 
occurs from collapse. At a meeting of the New York Pathological Soci- 
ety, held December 10, 1873, I presented a specimen, showing intussus- 
ception occurring about one foot above the ileo-csecal valve, in an infant 
aged thirteen months. On the day before its death, its previous health 
having been good, it seemed ill, and vomited once or twice, but did not 
appear to be in pain. It had two evacuations from the bowels, of the 
usual appearance, in the latter part of the day. On the following morn- 
ing it was unexpectedly in collapse, and died within about twenty-four 
hours from the commencement of the sickness. At the post-mortem ex- 
amination the cranium was not opened, but all the organs of the trunk were 
found normal except the intussusception. The mass involved in the dis- 
placement measured two and a half inches in length, and was slightly 
crescentic. The mucous membrane above and below it had the normal 
appearance, as did that of the external or incarcerating portion of the 
mass, while that of the incarcerated part was deeply injected. Water 
poured into the intestine above the invagination was wholly arrested by 
it. {New York Med. Rec, April 1, 1874.) But in the majority of in- 
stances death occurs from asthenia, which comes on gradually, but 
increases rapidly in consequence of the pain, vomiting, and imperfect 
nutrition. Children dying in this way may have convulsive movements 
more or less marked, but the prevailing characteristic as death approaches 
is extreme exhaustion. In exceptional instances the life of the sufferer is 
cut short by convulsions before the stage of exhaustion is reached. Thus 
a child aged three years, whose case was reported by Dr. Isaac Thomas, 
in the Amer. Med. Recorder, in 1823, and another, aged two years, whose 
case was reported by Dr. Coggswell, in the London Lancet, July, 1853,, 
died in convulsions on the second day. 

Treatment. — It is unfortunate, in cases of intussusception, that the 
time in which treatment can be of most service is apt to pass by before 
the true condition of the intestine is detected. Invagination being com- 
paratively rare, the patient is generally on the first day treated for colic 
or dysentery or some other common affection of the bowels ; and it is 
often not till the second day, when the intestine has become incarcerated, 
that the physician accurately diagnosticates the disease. The purgative: 



784 INTUSSUSCEPTION. 

medicines often given in the commencement injure the patient. In fact, 
both reason and experience teach us the impropriety of purgatives in this 
complaint. Cathartic remedies act as a vis a tergo, and may cause still 
further descent of the inverted intestine. Yet such powerful agents of 
this class as quicksilver have been employed. It was administered in 
two doses of one ounce each in one of the cases embraced in my statis- 
tics, but none of the mineral passed the bowels. At the post-mortem 
examination a considerable part of it was found in small globules, coated 
with a black layer consisting of the sulphuret or black oxide of mercury, 
in the intestine above the intussusception. It need not be added that the 
case was speedily fatal. 

The proper treatment of intussusception consists in attempts to reduce 
the displacement by pressure from below. This pressure may be applied 
either by liquid injections into the rectum or by inflation of the lower in- 
testine by air or gas. 

Injections should be made with lukewarm water, for cold or hot water 
may cause contraction of the muscular fibres of the intestine, and increase 
the constriction. The child should be placed in bed, or in the nurse's 
lap, with the nates elevated 45°. With the common India-rubber, or 
better the fountain-syringe, and the aid of an assistant, the liquid should 
be gently thrown into the rectum until the abdomen is somewhat dis- 
tended. By carrying the fingers, firmly but gently applied upon the ab- 
dominal walls, along the direction of the colon, the liquid is made to 
press against the lower end of the intussusception. The same gentleness 
and perseverance is required in kneading and pressing the abdominal walls 
as in the treatment of hernia, by taxis. If the invagination be in the de- 
scending colon, probably only a small quantity of the liquid can be in- 
jected, and it may be forcibly returned, but by repeating the injections, 
a sufficient quantity can ordinarily be introduced to obtain the full effect 
of the mode of treatment. There is also sometimes an increased irrita- 
bility of the rectum, even when the intussusception is at the other ex- 
tremity of the large intestine, so that tenesmus and expulsive efforts fol- 
low the introduction of the instrument. The assistant can aid in over- 
coming this by pressing the soft parts of the nates around the instrument. 

If the injection fail to reduce the displacement, it may be repeated after 
allowing the patient to rest for a while. In the New York Medical Jour- 
nal for May, 18*75, is the history of an interesting case, which was treated 
by Drs. Church and Warren of this city, and is reported by the latter. 
The infant was seven months old and had the usual symptoms, such as 
frequent paroxysmal pain in abdomen, vomiting, tenesmus, scanty muco- 
sanguineous stools. On the third day injections were twice employed 
without result, but on the fourth day an injection of ten or twelve ounces 
reduced the displacement, and the infant recovered. In a second case 
treated by Dr. Warren the age was nine months, and a tumor appeared a 



TREATMENT. 785 

little above the umbilicus a few hours after the commencement of the 
symptoms. The following is Dr. Warren's account of this interesting 
case, which will give a clear idea of the proper mode of treatment : 

" The patient was looking very pale and prostrated, the pulse was quick 
and feeble, and the skin cold. I at once determined to use fluid injec- 
tions, and, with the little patient placed in a semi-prone position in his 
mother's lap, with an ordinary Davidson's syringe I commenced injecting 
tepid soap and water, but after perhaps a gill had been thrown into the 
rectum, it was almost immediately rejected, very highly colored with 
blood, and mixed with it a very small quantity of mucus and faecal mat- 
ter ; the latter, by the way, not hardened, but of the consistency of soft 
putty. In a second attempt the fluid was retained longer, but was after 
a little while discharged, with more blood and mucus, but with much less 
tenesmus and pain. 

" When, soon after, I made my third attempt, the child's chest 
was rested upon the side of its mother's lap, with the lower extremities 
elevated by an assistant, so that the position was at an angle of about 
45°, anus upward. This time I injected the fluid very slowly, in 
order to avoid, if possible, the irritation caused generally by the frequent 
emptying and refilling of the syringe (which, by the way, is a very seri- 
ous hindrance to the successful use of this syringe, and which renders it 
much inferior to the fountain or hydrostatic). In this manner I succeed- 
ed in injecting, as I estimated at the time, perhaps ten or twelve 
ounces, and during the operation the child gradually became more quiet, 
and had, when I ceased, fallen asleep. Then, with the direction that oc- 
casional doses of tinct. opii camph. should be administered during the 
night, to control, if possible, the peristaltic action of the intestines, I left 
him. 

11 On the following morning, to my surprise, I found the child sleeping 
quietly and naturally, and I was informed that at about 5 a.m. (six hours 
after my visit) he had a movement of the bowels, which was saved for my 
inspection, and consisted simply of the enema, slightly colored with faecal 
matter. From that time he seemed to be entirely free from pain, and six 
or seven hours later had a natural passage, after which recovery pro- 
gressed rapidly, and in a few days he was discharged well." 

The following case is interesting as showing success from the use of in- 
jections after the lapse of two days, in a severe case, which had resisted 
treatment on the first day. The good result was apparently in great part 
due to the manipulation which was made so as to press the water against 
the course which intussusceptions are known to take. 

On September 10, 18*76, I visited, with Dr. Gillette, a nursing infant, 
aged nine months, whose history was as follows : It was habitually con- 
stipated, but it continued in its usual health till September 8, on which 
day it was carried by its nurse to one of the city parks. After its return 
50 



786 INTUSSUSCEPTION. 

it began to be fretful ; it vomited, and seemed to be in pain. It contin- 
ued to vomit frequently, especially after nursing, or taking drinks, and in 
the ensuing night passed two scanty stools of mucus and blood without 
faecal matter. In the morning of September 9th, Dr. G-. was summoned, 
who found the pulse 180, and temperature 102°, and the matter vomited 
greenish like bile. In the evening the temperature was 102f°. Dr. G. 
diagnosticated intussusception, and employed injections of water, but they 
were returned without bringing faecal matter, and without apparent result. 
He also administered opiates by the mouth. 

September 10th, temperature 102f° ; features pallid, beginning to 
have a pinched or sunken appearance, and indicative of much suffering ; 
no nutriment is apparently retained on account of the frequent vomiting, 
and the bowels are obstinately constipated. As the symptoms indicated 
rapid sinking and collapse, consultation was called at 4 p.m. It was im- 
possible to determine certainly, through the abdominal walls, on account 
of the distension, whether there was any tumor, but it was my opinion, 
and the opinion of one of the other physicians, that a tumor, hard and 
inelastic, could be felt nearly in the median line, between the umbilicus 
and the symphysis pubis. At about 5 p.m. the shoulders of the little 
patient were lowered, and the nates elevated, so that the trunk formed an 
angle of perhaps forty-five degrees with the horizontal, and a large quan- 
tity of tepid water was gently passed into the intestine through David- 
son's syringe, with the vaginal nozzle attached. It was impossible to esti- 
mate the quantity retained, since a considerable part of it escaped,, 
although the anus was firmly pressed around the instrument. 

When the abdomen was distended as fully as seemed justifiable, the 
nates being still elevated, and the liquid retained, so far as possible, by 
firm pressure upon the anus, the abdomen was firmly and deeply kneaded 
by the hand, the movements being made chiefly from the right lumbar 
toward the right inguinal, and from the right inguinal toward the hypo- 
gastric region. The kneading was continued perhaps eight or ten min- 
utes, and the water, which contained no perceptible amount of faecal mat- 
ter, blood, or mucus, was allowed to escape. 

After this operation the child became quiet, slept, and the vomiting 
ceased. At our next visit at 7 p.m., although the severe symptoms had 
in great part abated, and the countenance had lost that pinched and 
suffering aspect which was so prominent before, it was deemed best, in 
consultation, to repeat the injection, and this time through a rectal tube, 
which was introduced further than the nozzle employed at the preceding 
visit. The body was placed in the same position as before, and the abdo- 
men kneaded in the same manner. The water, when allowed to return, 
brought no faecal matter, but the last that flowed contained two shreds, the 
largest about one inch in length by two lines in width, resembling matted 
and nucleated epithelial cells. It was believed that they were composed 



TREATMENT. 787 

of such cells, with perhaps some of the mucous membrane to which they 
were attached, and that they were detached from the invaginated portion. 
An opiate mixture was now prescribed, to be given sufficiently often to 
relieve any restlessness, and keep the patient quiet, and a flaxseed poultice 
was applied over the abdomen. On the following day the temperature 
was 103^°, pulse 158, and the abdomen somewhat distended; but the 
vomiting had ceased, and there had been two fsecal evacuations since our 
last visit. The intussusception had been relieved, the inflammatory 
symptoms soon abated, and the infant's health was fully restored. 

Injections in order to be effectual, and give promise of success, must 
be aided by gravitation. Unless the nates be so elevated as to obtain 
the benefit of this hydraulic principle, I am convinced that inflation is 
more likely to reduce the displacement, and if, after sufficient trial of in- 
jections, relief be not obtained inflation should be employed. Inflation 
produces an equable and effective distension of the external or incarcerat- 
ing portion of intestine, and cases of cure by inflation have been reported 
after injections had failed. Treatment by inflation, which indeed ought 
to occur to any intelligent physician appreciating the anatomical condi- 
tion of the parts, as the correct mode, was prominently brought to the 
notice of the profession in modern times by Mr. Samuel Mitchell, in a 
communication to the London Lancet for March 17, 1838. 

" I take the liberty," he writes, " of suggesting to the profession, 
through the medium of your valuable periodical, the trial of inflating the 
bowels by means of a glyster-pipe attached to a common pair of bellows ; 
it has fallen to my lot to witness several of these most distressing cases in 
children ; the nature of the obstruction was foretold during life, and un- 
fortunately verified by post-mortem examination. The last case of the 
kind which came under my care, about two years since, presented all 
the usual symptoms : intolerable restlessness, the most obstinate sickness, 
the singularly distressed state of countenance, and shrunken features. 
The usual remedies were had recourse to, viz., warm baths, glysters, ano- 
dyne frictions over the abdomen, etc., but without avail. As a forlorn 
hope I made trial of inflation by the above means, with the most happy 
result. The sickness immediately ceased ; the child within an hour 
passed a natural stool, and in the morning was almost without ailment." 

This mode of treatment is termed novel in the Lancet, but it is really 
as old as the time of Hippocrates, who speaks of throwing air into the 
bowels, by which flatulence is imitated (flatus immitatur). (Hippocrates' 
Works, translated from the Greek by Grimm, 4 bd., page 198.) 
Haller also recommended the same treatment : " Flatus etiam immissus 
celerrime susceptionem dispellet. " (Physiologia Corporis Humani, torn, 
vii., p. 95.) In the Edinburgh Medical Journal, October, 1864, Dr. Da- 
vid Greig relates Ave cases of • successful treatment of intussusception by 
inflation. The first, an infant six months old, previously in good health, 



788 INTUSSUSCEPTION. 

suddenly became very fretful, apparently having severe paroxysmal pain 
in the abdomen. She had vomiting, and finally tenesmus, with bloody 
evacuations. Warm-water enemata could not be employed on account, 
the writer thinks, of the spasmodic action of the intestines, and an ab- 
dominal tumor could be distinctly felt near the umbilicus. Castor oil and 
a purgative powder, and enemata of water having been employed in vain, 
and the case becoming really critical on the second day, inflation was re- 
sorted to. The writer says : " The nozzle of a small pair of bellows was 
introduced into the anus, and air injected to a considerable extent. Con- 
trary to our expectation, the air passed readily into the bowel, and seemed 
to give the child great relief. After the injection it lay very quiet, as if 
asleep, and evidently quite free from pain. In about twenty minutes 
from the time the air injection was administered, a slight rumbling noise 
was heard in the child's abdomen, followed by a crack so loud and dis- 
tinct as to alarm the attendants in the room, who thought something had 
burst in the child's bowels. The child, however, continued as if asleep, 
and free from pain, and in about half an hour a large feculent stool, 
slightly mixed with blood and mucus, was passed without pain. During 
the night the child rested pretty well, had no return of vomiting, took 
the breast as usual, and in two days was quite well." 

Another child, nine months old, treated by Dr. Greig, presenting 
nearly the same symptoms and the abdominal tumor, also obtained relief by 
inflation, after castor oil and enemata had failed to produce any benefit. 

An apparatus for the production and injection of carbonic- acid gas has 
been invented by Schultz and Warker, of this city, and is manufactured 
by them. It consists essentially of two glass chambers, one over the 
other. In the lower one a bicarbonate is placed, and in the upper an acid 
in a liquid state. By the gradual admixture of the two, carbonic acid is 
set free. An elastic tube conveys the gas from the lower chamber. The 
apparatus has been used by physicians of the city for the reduction of in- 
tussusception and other purposes, and is a useful invention. 

The same firm, and several others in this city, prepare for the shops 
large bottles of highly charged carbonic-acid water, from which when in- 
verted a powerful current of carbonic-acid gas can be obtained. Two or 
three of these bottles, with a portion of the tube from Davidson's 
syringe, which can be readily attached to the stem from which the gas 
escapes, constitute all that is required for an ordinary case. 

The following cases, which I treated with Dr. Biichler of this city, in 
1871, show what may be achieved by inflation, and also the unfavorable 
result which must inevitably occur in certain cases. A German infant, 
five months old, nursing, began to be fretful, crying often, on March 7th, 
and before night passed a scanty motion of blood. The symptoms con- 
tinuing, I was asked to examine the infant on the 10th, and learned the 
following facts : It had vomited daily, had had daily scanty but infre- 



TREATMENT. 789 

quent stools, consisting chiefly of blood, accompanied at first by tenes- 
mus, but not within the last day ; it continued to nurse, but was becom- 
ing thinner and weaker, and was evidently in pain. The symptoms indi- 
cating the nature of the disease, the abdomen, which was not distended, 
was examined for the tumor, which was found in the right side in the 
site of the ascending colon, apparently about one and a half to two 
inches in length ; pulse 124 in sleep ; no cough. An ineffectual attempt 
was made to reduce the intussusception by a very rude and imperfectly 
constructed apparatus (the bellows), when from the lateness of the hour 
further treatment was postponed till early the following morning. 11th. 
Tumor still detected in the right lumbar region ; pulse 120 asleep, 150 
awake. By means of Schultz and Warker's apparatus, the intestines were 
inflated so as to produce very decided prominence of the abdomen, and 
the abdomen gently kneaded. After some minutes the gas was allowed 
to escape, when the tumor had disappeared. In a few hours, a natural 
evacuation occurred from the bowels, and the infant has remained well 
since. 

The second case ended unfavorably, although the symptoms were appa- 
rently no more grave than in the case just related, and had continued a 
shorter time. This infant was also of German parentage. The tumor, 
firm and elongated, could be distinctly felt in the left lumbar region. In 
this case the inverted bottles of carbonic-acid water were employed, and 
when, after considerable delay and kneading of the abdomen, the gas was 
allowed to escape from the intestine, the tumor had disappeared. A few 
hours afterward convulsions occurred, ending fatally. At the autopsy the 
invaginated mass, which was too firmly strangulated to admit of reduction 
by inflation, was found in the epigastric region, having been carried up 
from its former position by the inflation of the intestine below. It con- 
sisted of the terminal part of the ileum, which had passed through the 
ileo-caecal orifice, and become incarcerated in the ascending colon, and, 
as is not unusual in these cases, the action of the intestines had changed 
the location of the tumor in the abdomen from the right to the left 
side. 

Whether air or carbonic acid be employed, it is necessary to produce 
distension of the intestine to its fullest extent below the seat of the com- 
plaint, without endangering rupture, and of course the sooner it is used 
the better the chance of success. In a few days the displaced intestine 
has, in a large proportion of cases, become so firmly incarcerated, and has 
descended so far, that attempts to replace it, either by injections or infla- 
tion, are unsuccessful ; still, even at a late period, a persevering attempt 
should be made if it have not previously been tried. If injections and in- 
flation fail to effect the desired result, the employment of quicksilver, by 
the rectum with the thighs elevated, has been suggested to me as worthy 
of trial by a physician of large practice in this city, who has had consid- 



790 INTUSSUSCEPTION. 

erable experience with intussusceptions. This may be a useful sugges- 
tion, especially if the invagination be in the descending colon. 

If the modes of treatment which I have recommended above, fail to 
give relief when perseveringly and sufficiently employed in a case of acute 
intussusception, the patient's state is one of extreme peril, and the prog- 
nosis is unfavorable. Yet recovery is possible in one of two ways, 
namely, by incision through the abdominal walls (laparotomy), and reduc- 
tion of the displacement by the fingers within the abdominal cavity ; and 
secondly, by sloughing of the invaginated mass, and union by adhesive 
inflammation of the ends of the intestine which have preserved their vital- 
ity. Atrophy of the imprisoned part so seldom occurs in a case which 
has resisted injections and inflation, that it need not be considered in this 
connection, as a mode of recovery. 

Laparotomy has been successfully performed in a child aged two years, 
as I have stated above, by Dr. Jonathan Hutchinson, of London. The 
case was one of those exceptional ones in which great displacement had 
occurred without strangulation. It had continued as indicated by the 
symptoms about one month, and a portion of the intestine terminating in 
the ileo-caecal valve had extended several inches from the anus. " The 
patient was anaesthetized by chloroform, and the abdomen was opened in 
the middle line below the umbilicus. The intussusception was then easily 
found, and as easily reduced. The after-treatment consisted only in the 
administration of a few mild opiates, and the child made a rapid recov- 
ery." (See London Lancet, November 22, 1873.) In a case of this 
kind, there can be no doubt of the propriety and necessity of laparotomy 
as a last resort, for there being no strangulation, sloughing could not 
occur, and death sooner or later, from exhaustion, must be the probable 
result. Cases of this sort have usually been left to perish, after the ordi- 
nary modes of relief have failed. Thus as far back as 1784, M. Robin 
published in the Mem. de V Acad, de Chirurg., the case of a child aged 
3 J- years, who died after the lapse of three months, with a caecum pro- 
truding from the anus. And in the Amer. Journ. of Med. Sci. for 1849, 
Dr. Worthington published a similar case, in which a child aged three 
years and four months lived even a longer time. In these days of anaes- 
thetics, and with the brilliant success of Hutchinson, a physician would in 
my opinion be reprehensible if he allowed a child aged two years or over, 
with this form of the displacement, to perish without strongly advising 
laparotomy. 

But the question arises, whether in those more frequent cases of intus- 
susception in young children, in which after the displacement has con- 
tinued a few hours, there is such firm constriction of the invaginated 
mass, that the patient suffers much pain and constitutional disturbance, 
and probably passes bloody stools, and injections and inflation have failed 
to reduce the displacement, laparatomy is justifiable. This operation, in 



TREATMENT. 791 

the case of infants, has heretofore been regarded as so dangerous, and so 
likely in itself to prove fatal, that the profession have generally consid- 
ered it unjustifiable, believing that, although death was nearly certain 
without it, the performance of it did not increase the chances of a favor- 
able result. Dr. J. B. Sands, of New York, has recently shown that 
laparotomy is justifiable, as a last resort, for the relief of this form of in- 
tussusception, even in the youngest infants ; and in the following case, 
recorded in the New York Medical Journal, June, 1877, saved the pa- 
tient, who doubtless would otherwise have perished. 

On March 11, 1877, an infant of six months suddenly presented the 
characteristic symptoms of intussusception, such as tenesmus, abdominal 
pain, vomiting, and bloody stools. A few hours later, when Dr. Sands 
was called, the pulse was rapid and feeble, with symptoms of collapse. 
An elongated tumor could be felt in the abdomen, extending from the left 
iliac region to the left hypochondrium, inelastic, tender on pressure, and 
dull on percussion. The lower end of the invaginated mass could be 
readily touched by the finger introduced into the rectum. The usual 
methods to effect reduction were at once employed with partial success, 
for the tumor disappeared from the site where it had been discovered, and 
was reduced to a small and firm mass, on a level with the umbilicus, but 
it resisted any further attempts to effect its reduction. 

Dr. Sands then, having etherized the patient, made an incision in the 
median line of the abdomen, extending downward about two inches from 
a point a little below the umbilicus. Through this opening, proceeding 
cautiously, and using as little violence as possible, he was able after some 
delay to reduce the displacement. The invaginated mass, which was 
only one and a half inches in length, consisted of the terminal portion of 
the ileum and the caecum, which had entered the ascending colon. The 
wound was closed by five silver sutures, which embraced the peritoneum, 
and the patient made a good recovery. The operation was performed 
eighteen hours after the commencement of symptoms. 

Dr. Sands has collected the statistics of twenty cases of laparotomy for 
intussusception occurring at different ages, in which the result was stated. 
Of these, seven recovered, or one in three ; but he judiciously remarks, 
considering the gravity of the operation, that it is doubtful whether 
future statistics will show so favorable a result of laparotomy for this dis- 
placement, as to justify the frequent use of the knife. For facts and sta- 
tistics relating to this subject the reader is referred to an able and elaborate 
paper by Dr. Ashhurst, published in the American Journal of the Medical 
Sciences for July, 1874. 

It is obvious that the earlier the displacement is recognized, the greater 
the probability of the reduction by the judicious use of injections and in- 
flation, and it is seen from cases related above that this treatment may be 
successful as late as the second or third day, after previous attempts to 



792 INTUSSUSCEPTION. 

reduce the intussusception by the same means have failed, and when there 
is that degree of strangulation that bloody stools occur. But as my own 
experience has shown me, there is also inevitably a large proportion of 
cases in which the use of injections and inflation, however judiciously and 
perseveringly made, totally fail, and it seems to me, in the light of pres- 
ent experience, that when pressure from below by water, air, or gas, which 
is the only efficient mode of treatment short of the knife, has been tried 
sufficiently long and often without result, that it is the duty of the phy- 
sician to seek surgical advice in reference to laparotomy, as he would in a 
case of hernia, especially since, under Lister's antiseptic method, the dan- 
ger from severe operations appears to be considerably diminished. It 
may be added that laparotomy performed on the first or second day, will 
be much more likely to save life in ordinary cases than if performed later, 
since the strangulated intestine is soon badly damaged, and a local peri- 
tonitis is apt to be developed any time after the first forty-eight hours-. 
When an intussusception has reached that stage in which active inter- 
ference is no longer proper, the physician can only prescribe opiates, with 
sustaining measures and an emollient poultice over the abdomen, and 
must await the result. The diet should consist of beef juice and other 
concentrated nutriment, which leaves little residuum. Vomiting, which. 
is so common, is best controlled by bismuth and opiates ; convulsions 
require the bromide of potassium, and an enema of three to five grains of 
chloral hydrate, dissolved in a little water. 



SECTION IV. 

DISEASES OF THE CIRCULATORY SYSTEM 



CHAPTER I. 

CYANOSIS. 



Certain of the diseases which pertain to the circulatory system have 
been treated of in other parts of this book (umbilical haemorrhage, gastro- 
intestinal haemorrhage, etc.). It remains to consider that general condi- 
tion of the blood which is designated morbus caeruleus or cyanosis. 

In 1863, I read before the New York Academy of Medicine a statis- 
tical paper on cyanosis, which was published in the Transactions of that 
Society. This paper contains an analysis of 191 cases, collated from the 
various European and American medical journals, and to these cases I am 
indebted for most of the following facts pertaining to this disease. 

The term cyanosis or blue disease is differently employed by writers. 
Some apply it to cases of transient lividity occurring in the course of 
acute diseases, as well as to those cases which depend on permanent struc- 
tural changes, or on malformations. I apply this term, as do most patholo- 
gists, only to the latter cases. 

Some are inclined to discard the consideration of cyanosis as a disease, 
regarding it rather as a symptom. Their view is, in my opinion, correct 
in reference to the cyanotic state which occurs in certain acute diseases, 
but not in reference to cyanosis, as I have denned the term and employ 
it. The propriety of considering cyanosis a disease is more apparent if 
we are not misled by the term which designates it. Lividity is not its 
most important or its essential characteristic. It is simply a sign, 
although conspicuous, and, indeed, the only one by which the disease can 
be readily recognized. Cyanosis is, in reality, a blood disease, its patho- 
logical state consisting in a deficient oxygenation of this fluid, or in an 
excess in it of carbonic acid, and probably of carbonaceous products. It 
should be placed in the same category with leucocythaemia and melanse- 
mia. 

Statistics show that cyanosis is, with very few exceptions, due to mal- 



794 CYANOSIS. 

formation in the circulatory system, and at the centre of circulation, 
namely, in the heart and in the large vessels which arise from this organ. 
In exceptional cases the cause of the cyanosis is located in the lungs, and is 
in all or nearly all instances either extensive emphysema in both lungs, firm 
and thick fibrinous exudation over both lungs, compressing them by its 
contraction and causing, perhaps, carnification in parts of them, or the 
cause is compression of the lungs from caries of the vertebrae, and conse- 
quent depression of the ribs. These causes pertain to youth and man- 
hood rather than to infancy and childhood. On account of this fact and 
the rarity of such cases they need not be considered in this connection. 

Literature of Cyanosis. 

The ancient physicians, so far as can be ascertained from their writings 
still extant, were ignorant of cyanosis ; whether they overlooked it, or 
whether those early ages were exempt from it and the malformation on 
which it depends is peculiar to a posterity physically degenerate. The 
blue disease described by Hippocrates {Be Morbis, lib. ii., sec. v., page 
485, Ed. de Foe's, 1621) was probably some acute febrile affection. 
Galen, whose voluminous writings, with an excellent index, are still ex- 
tant, and whose comprehensive mind embraced the whole range of medi- 
cal science of the second century, makes no mention of it, so far as I can 
find. In the middle ages, as appears from the remark of Boerhaave 
{Diseases of the Humors, Acad. Lect., § 732), the common people be- 
lieved the cyanotic to be the victims of evil spirits ; and it is probable 
that physicians, during this long period of superstition and intellectual 
lethargy, embraced the popular belief. 

On the revival of learning, pathological anatomy began to be more 
thoroughly and intelligently studied ; but it is evident that before the 
great discovery of Harvey, in the lVth century, it was impossible to refer 
cyanosis to its true cause. In the latter part of the century so favor- 
ably opened by Harvey's genius, malformations of the heart were ob- 
served and described by some pathologists on the continent, in cases in 
which cyanosis must have been present ; but it is uncertain, from the 
brief records which they have left, whether any of them understood the 
dependence of this disease on the abnormal state of the heart. Boer- 
haave, in the beginning of the 18th century, attributes " a livid or black 
color diffused throughout the whole skin," evidently referring to cyano- 
sis, to " 1, a relaxation of the vessels, while the vis a tergo' remains the 
same, or, 2, to a too sudden increased pressure behind, without a relaxa- 
tion of the vessels." Vieussens, who was a contemporary of Boerhaave, 
and was more thorough in the examination of morbid as well as healthy 
structures, narrated the history of a cyanotic patient, with a description 
of the malformation, but the one who first gave particular attention to 



LITEEATURE OF CYANOSIS. 795 

the blue disease was Morgagni. This Paduan professor, excelling his 
predecessors in thoroughness of observation and accuracy of deduction, 
published a theory in explanation of the disease which now, after the 
lapse of more than a century, has many adherents. In the same century 
with Morgagni, the 18th, but subsequently to his time, Drs. Pulteney, 
Wm. Hunter, Baillie, Wilson, and Abernethy in Great Britain, and 
Jurine and Sandifort on the continent, may be mentioned among those 
who contributed to a knowledge of cyanosis, by the publication of cases, 
with a description of the malformations. Yet, when the present century 
commenced, no monograph or dissertation had appeared on this disease ; 
and, notwithstanding the publication of cases from time to time, the pro- 
fession generally were almost totally unacquainted with its nature. No 
better idea can be given of the prevailing ignorance, in reference to cyano- 
sis at this period, than by quoting from a case related by Ribes in 1814. 
[Bull, de la Fac. de Med., 1815.) The patient had some time previously 
received an injury of the finger. " Many physicians of Amsterdam," 
says he, " were at different times consulted on the subject of this affection, 
no one of whom understood its true cause, its essential character. One 
considered it as partaking of the nature of epilepsy, and caused by the 
irritation in the nervous system which the wound in the finger had pro- 
duced. Others attributed it to the presence of intestinal worms. Some 
physicians pronounced it an injury of the liver or spleen. Many held it 
to be a scorbutic affection. One only believed it to be the result of an 
unknown organic disease." 

Since the commencement of the present century the blue disease has 
received a large share of attention. According to Forbes' s Medical Biog- 
raphy, the first dissertation on this subject appeared in 1805, from the 
pen of Seiler, and from this time till 1832 no fewer than twenty-eight 
dissertations or monographs were published, either on cyanosis or on 
malformations which produce it or at least relate to it. In the list of 
writers are some of the most eminent names in the profession, as Louis 
and Bouillaud. The number who have written on this subject since 
1 852 probably exceeds the number of previous writers. Of those who 
have contributed most to our knowledge of the disease may be mentioned 
F;irre, Chevers, and Peacock in Great Britain, Gintrac on the continent, 
and Moreton Stille in this country. Farre, Chevers, and Peacock wrote 
on malformations of the heart, alluding incidentally to cyanosis, but their 
writings contain valuable matter for statistics bearing on the latter sub- 
ject. Farre's book was published in 1814, and is out of print ; Chevers 
published his papers in the London Med. Gazette, commencing in the 
year 1845 and running through several successive volumes. Peacock's 
treatise was published in 1858. It contains several original cases, pre- 
viously narrated by him to the London Pathological Society. The paper 
by Moreton Stille, which has attracted much attention, especially in 



796 CYANOSIS. 

Europe, was his inaugural thesis, and was published in the Amer. Med. 
Journ. of Med. Sci., in 1844. 

This paper relates entirely, in the words of the author, to " the laws 
of the causation of cyanosis. ' ' The only really complete statistical paper 
on the blue disease is that by M. Gintrac, published in 1824, in Paris, 
and embracing all the cases which had been accurately reported up to 
that time, namely, fifty-three, He, indeed, exhausted the subject for the 
period in which he wrote, but on account of the accumulation of mate- 
rial since, his monograph now seems incomplete. 

Two theories in explanation of the occurrence of cyanosis have divided 
the profession : the one attributing it to obstruction at the centre of cir- 
culation, and consequent venous congestion ; the other, to admixture of 
venous and arterial blood through openings in the septa of the heart, or 
through the ductus arteriosus. The former of these theories originated 
with Morgagni more than one hundred years ago, and is essentially the 
same as that advocated by Stille. Stille errs in placing Morgagni among 
the advocates of the other system. The second theory, or that which 
attributes cyanosis to admixture of venous and arterial blood, is said by 
Dr. Peacock to have originated with Hunter, but its ablest supporter was 
Gintrac. Of late there are some pathologists who do not believe that 
either theory is sufficient to explain the cause of c}^anosis, but that the 
true explanation lies somewhere between the two. Among the most con- 
spicuous of these is Prof. Walshe, of London. These theories will be 
considered in the proper places. 

Sex. — Writers on cyanosis state that there is a preponderence of 
males to females affected with it. Aberle, of Vienna, says that two 
thirds were males in an aggregate of 180 cases which he collated. In 
Gintrac's cases, 28 were males and 16 females ; in Stille' s, 41 were 
males and 31 females. The sex is recorded in 134 of the cases collected 
by me, of which 78 were males, 56 females ; and if those cases are ex- 
cluded in which cyanosis was due to obstruction at the mouth of the pul- 
monary artery, the number of the two sexes is the same. In the five 
years commencing with 1858, according to the mortuary returns, 207 
died in this city from cyanosis, of which number 117 were males, 90 
females. In England, for two years, 418 males died of cyanosis, and 273 
females. Although statistics of different cities and countries agree in the 
fact of an excess of males over females, there does not appear to be that 
great preponderance of males which the earlier writers on this disease 
believed to exist. 

Causes of the Malformations. — Mothers sometimes attribute the 
malformations, and probably correctly, to strong mental impressions felt 
during utero-gestation. The mother of a patient treated by Dr. Peacock 
stated that " two months before her confinement, she was frightened by 
seeing a child killed, and never recovered from the shock she sustainedo" 



CAUSES OF THE MALFORMATIONS. 797 

(Malf. of Heart, p. 37.) In another case " the mother was much out 
of health, and stated that, when pregnant with the child, she was greatly 
alarmed by seeing a man who was dying of asthma." (Op. cit., page 
57.) In another instance the mother was frightened at the fifth month 
of pregnancy (page 41) ; and in still another case, recorded by Dr. Pea- 
cock, the mother, four or five months before her confinement, " was 
greatly alarmed by her husband, who was insane, standing over her for 
two hours with a loaded pistol." (Page 43.) 

Occasionally the malformation appears to be due to some vice or taint 
in the system of one or both parents. In a case quoted in the Gazette 
Medicate, for December 28, 1850, from another continental journal, it is 
stated that " the mother, who had formerly suffered from rickets, gave 
birth to five children, all of whom died immediately or shortly after birth 
with symptoms of cyanosis. The father died at the age of thirty-six of 
phthisis. ' ' Dr. Peacock relates a case in which the father was livid, and 
had the " pigeon-breast" common in the cyanotic. In the history of a 
patient, which was communicated by Cooper to Farre, it is related that 
*' vices of conformation of the heart appeared to have been inherent in 
the family. Of 12 infants only 4 survived, and more presented signs of 
heart disease." Dr. Buchanan relates the history of a child which was 
the second that had suffered and died in the same family in the same 
way. A patient treated by Mr. Leonard was the sixth child of a family, 
who had died at about the same age, with symptoms of cyanosis. Such 
instances are, however, exceptional. Ordinarily, the cyanotic have not 
only healthy parents but healthy brothers and sisters. 

A patient whose history is given by Dr. William Hunter was born at 
the eighth month, but in nearly all other cases the full period of intra- 
uterine existence was reached. 

The opinion was expressed by Gintrac that the number affected with 
cyanosis to the entire population, varies in different countries. It is 
probable that the occurrence of the blue disease is not greatly, if at all, 
influenced by the nationality, but it is certainly dependent to a considera- 
ble extent on the condition of society. It is less frequent in a commu- 
nity in comfortable circumstances, and engaged in wholesome and quiet 
occupations. Pure air and outdoor exercise, plain, nutritious diet, free- 
dom from cares and anxieties, in fine, causes which promote the physical 
well-being, diminish the liability to an ill-formed and cyanotic offspring. 
And, conversely, impure air, improper and insufficient diet, grief, etc., 
increase the percentage of cyanotic cases. Hence, it is a rare disease in 
the rural districts, and comparatively frequent in the cities, especially in a 
large city like New York, which contains a numerous indigent and care- 
worn population, living from year to year in the midst of agencies which 
operate stealthily but certainly to enervate the system and undermine the 
health. 



798 CYANOSIS. 

These remarks are abundantly substantiated by statistics. In New 
York City for the six years ending with 1860, one death resulted from 
cyanosis to 436 deaths from all causes ; and in Brooklyn the proportion 
estimated for two years was about the same. On the other hand, in the 
State of Kentucky, which contains few large cities, and in the death 
reports of which cyanosis is included in the general term malformation, 
there was, during a period of five years, one death from malformation to 
2469 from all causes. In the State of South Carolina, for three years, 
one death resulted from cyanosis to 5018 from all causes. In the State 
of Massachusetts, for two years, there was one death from cyanosis to 
1136 from all causes, and two thirds of the cyanotic cases occurred in the 
counties of Suffolk, Essex, and Worcester, which contain large cities. In 
London one death occurred from cyanosis to 755 from all causes during 
a period of three years. On the other hand, in England, including the 
city of London, there was, for the ten years ending with 1857, one death 
from cyanosis to 1589 from all causes ; and in the rural districts of Mon- 
mouth and Wales only one death occurred from cyanosis to 5578 deaths 
from all causes during a period of two years. 

Time of Commencement. — It is an interesting and somewhat remark- 
able fact that cyanosis, though dependent on a malformation, does not. 
always commence at birth, or, at least, that it does not exist in degree 
sufficient to produce the cyanotic hue till some time has elapsed after 
birth. In 138 of the cases of cyanosis which I have collected, the time 
at which lividity was first observed is stated as follows : In 97 it was 
within the first week, and generally within a few hours of birth. In the 
remaining 41 cases it commenced as follows : 

In 3 at 2 weeks. In 6 from 2 years to 5 years. 



1 " 3 " 


" 1 "5 " ' 


10 


2 " 1 month. 


" 6 " 10 " " 


20 


7 from 1 to 2 months. 


" 1 " 20 " " 


40 


5 " 2 " 6 " 


" 1 over 40 years. 




5 " 6 " 12 " 


— 




3 " 1 year to 2 years. 


41 





In these 41 cases, in which blueness did not occur till after the age of 
one week, if the patient were less than two years old when it commenced 
there was frequently no obvious exciting cause, but above this age, with 
three exceptions, such a cause is known to have been present. It is in- 
teresting to observe how trivial the exciting cause frequently is, and 
equally interesting to note how long patients have enjoyed good health, 
not having the least lividity, although the anatomical vice, to which the 
final development of cyanosis was due, had existed from birth. 

Dr. Theophilus Thompson relates, in the Medico- Chir c Trans., vol. 
xxv. , the history of a lady, thirty-eight years old, who was well till an 
attack of Asiatic cholera, after which her health was permanently im~ 



SYMPTOMS. 799 

paired. Two years before her death she passed through a course of fever r 
and from this time was cyanotic. In the Philadelphia Medical Exam- 
iner, June, 1850, Dr. Waters relates a case in which cyanosis began at 
the age of six years in an attack of measles. In a case published by 
Mr. Napper, in the London Medical Gazette, 1841, the child fell at the 
age of six months, and from this time had cyanosis. A female, whose his- 
tory is given by Prof. Tommasini, of Bologna, and quoted by Bouillaud, 
became cyanotic at the age of twenty-five in consequence of difficult par- 
turition. In the London Lancet, 1842, Mr. Stedman relates a case, in 
which cyanosis began at the age of ten weeks in an attack of convulsions. 
In the American Journal of Medical Sciences, 184V, Dr. John P. Harri- 
son published the history of a baker, twenty years old, in whom cyanosis 
began five years previously after great effort in carrying wood. Louis 
and Bouillaud quote from M. Caillot the case of a child, who became 
cyanotic at the age of two months in an attack of hooping-cough. Louis 
also narrates a case in which hooping-cough had the same effect at the 
age of twelve years. Ribes treated a child in whom the blue disease be- 
gan at the age of three years from a severe contusion of the fingers. In 
a case related by Marx it commenced at the age of ten months from a 
blow on the back, inflicted by the mother. In the Medical Times and 
Gazette, for 1855, Mr. Speer gives the history of a female, who at the 
age of thirteen years was put in a place requiring considerable exertion, 
and from this time was cyanotic. A patient, whose case is related by 
Cherrier, fell into a deep ditch in the winter season, and immediately 
after had a low fever, from which the blue disease commenced. In a 
case published by Tacconus the exciting cause was believed to be fright, 
in consequence of a fall from a great height, and in another, related by 
Bouillaud, it was a blow received on the epigastrium after the patient had 
passed the age of fifty years. Similar cases are related by Mayo and 
Peacock. 

It will be seen that the exciting cause of cyanosis is usually such as pro- 
duces a profound impression on the system, and affects the action of the 
heart. Precisely in what way it operates to develop the disease has not 
been satisfactorily explained. Mr. Mayo conjectures, that in the case 
related by him there was previously some compensation which ceased, or 
became inadequate in consequence of some change produced in the econ- 
omy. Although cyanosis may not appear for months or even years, there 
is rarely improvement when it is once established. Appearances of 
amendment are deceptive. The disease when not stationary is progres- 
sive, and this explains the fact that few survive the middle period of life. 

Symptoms. — The symptoms in cyanosis vary in intensity in different 
patients, and in the same patient at different times, being milder if he be 
quiet and the mind calm, more severe if active, or if the mind be agitated. 
In mild cases, in a state of rest, they nearly or quite disappear, so that a 



800 CYANOSIS. 

stranger would not suspect that there was any serious ailment. They are 
aggravated by any cause which accelerates the action of the heart. In 
some patients, cyanosis is increased by the most trivial disturbing influ- 
ences, among which may be mentioned nursing, dentition, crying, coughing, 
and slight emotions of joy, sorrow, or anger. In more than one case it 
has been perceptibly increased by the stimulus of digestion, the color be- 
ing deeper after a full meal than before. 

The cyanotic hue varies in different individuals from duskiness to a 
deep purple, almost black color. It is usually most marked in the vis- 
age, especially the palpebrae, cheeks, nose, and lips, in the ears, fingers, 
and toes, and upon the mucous surfaces. It is sometimes, without any 
assignable cause, confined to a portion of the body. In a case related by 
Mr. Steel in the London Lancet, 1838, the upper part of the body was 
livid and oedematous, and the lower part pallid and shrunken, and yet the 
malformation was of the kind which is commonly present in cyanosis. In 
the London Medical Times, March 8, 1845, copied from the Gazette 
Medicate, is the history of a child six years old, in whom the color was 
deeper on the right than left side. There had been, however, hemiplegia 
of this side in infancy, but this had entirely passed off. On the other 
hand, in a case of rare malformation communicated by Cooper to Farre, 
in which the upper part of the system was supplied chiefly by arterial and 
the lower by venous blood, the discoloration was general. In exceptional 
instances livid maculae, like those of purpura, have been observed upon 
the skin. 

Those affected with cyanosis have generally at birth been well formed 
and of the usual size, and in most cases, for a considerable period after 
birth, the appetite is good, bowels regular, and the system well nour- 
ished. But when cyanosis becomes so severe, as it does sooner or later, 
that its symptoms are rarely absent, digestion is imperfectly performed, 
and the body becomes either emaciated or stunted and puny. It may be 
stated, as a rule, that nutrition is in inverse proportion to the gravity of 
cyanosis. In thirty-three out of forty-one cases, in which the condition 
of the system, as regards nutrition, was recorded either a short time pre- 
viously to death or at the autopsy, the body was either considerably 
emaciated or else diminutive, and those who were well nourished were 
usually such as had died early, or of some intercurrent disease. 

In this connection may be mentioned two abnormalities which have 
been observed in the cyanotic. The chest is often flattened laterally, with 
a projecting sternum, so as to present an appearance generally described 
in the records as ' ' pigeon-breasted. ' ' Sometimes the most prominent 
part is directly over the heart, and in one or two cases the sternum was 
observed to be deflected toward the left. In the majority of the records, 
however, no mention is made of the external appearance of the chest. 

The other abnormality is frequently observed in chronic diseases of the 



SYMPTOMS. 801 

heart and lungs, in which there is sluggish circulation and consequent al- 
tered nutrition in the fingers and toes. In twenty-eight cases it is stated 
that the tips of the fingers or toes, or both, were bulbous. This hypertro- 
phy, if slight, is likely to be overlooked, and that it was observed and 
recorded in so many cases renders it probable that it was present in a much 
larger number. In one case the anatomical character of this enlargement 
was examined, and was found to consist chiefly of hypertrophied connec- 
tive tissue. 

The nails are often incurvated over the deformity. At a meeting of the 
Lond. Path. Soc, in 1859, Mr. Ogle narrated the history of a laborer, 
fifty years old, who had swelling, numbness, and lividity of the left arm, 
from pressure of an aneurism, and the fingers on this side were clubbed 
as in cyanosis. A patient whose history is related in the Glasgow Medi- 
cal Journal, and who was believed to be cyanotic in consequence of a 
highly emphysematous state of the lungs, had a similar development of 
the tips of both fingers and toes. 

An interesting feature in cyanosis is the low grade of animal heat. 
The temperature of the body is in all cases below that of health. This is 
especially noticeable in the extremities. There has not been a sufficient 
number of accurate thermometric observations to determine whether the 
internal heat is usually reduced. The following only have been recorded : 
Mr. Fletcher relates the history of a young man in the Medico- Chir. 
Trans. , vol. xxv. , in whom the thermometer placed in the mouth did not 
stand above 80° Fahrenheit. Hodgson reports the case of a man, twenty- 
five years old, in whom the thermometer placed under the tongue rose to 
100°, while in his own case it was two or three degrees below that term. 
In an experiment, recorded by Nasse, the instrument placed in the mouth 
fell little if at all below the healthy standard ; applied to external parts, 
it stood at about 21° Reaumur. 

The lack of heat is the source of great discomfort to a cyanotic patient. 
In mild weather he requires a fire to keep him warm, or an amount of 
clothing which to others would be intolerable, and in cold weather slight 
exposure strikes him with a chill. Nor can he increase his heat by active 
exercise, since his infirmity disqualifies him for this. 

Although the temperature of the surface is so low, the occurrence of 
perspiration, sometimes profuse, is mentioned in several of the records. 

In severe cases of cyanosis the generative system is imperfectly devel- 
oped. In the female, menstruation is scanty or delayed, and in the male 
signs of puberty are feebly manifest. If the disease be so mild that the 
symptoms are absent when the patient is in a state of repose, these 
organs attain nearly or quite their normal development. The catamenia 
have appeared as early as the age of sixteen years ; and a cyanotic pa- 
tient treated by Cherrier had two children, but they both died of scrofu- 
lous affections. 
51 



802 CYANOSIS. 

The action of the heart is necessarily much involved. In mild forms of 
the disease, if the patient be quiet, this organ may beat with considerable 
slowness and regularity, but in all cases exercise or excitement, which in 
a state of health would scarcely have any appreciable effect on the pulse, 
embarrass its movements, and produce palpitation. In severe cases pal- 
pitation is rarely absent, and the pulse is frequent, feeble, and often in- 
termittent. In a large proportion of patients bruits are produced by the 
irregular circulation through the heart. 

The respiration corresponds with the action of the heart. It is accel- 
erated in proportion to the frequency of the pulse. The suffering in this 
disease is largely due to paroxysms of palpitation and dyspnoea. These 
occur sometimes without any apparent exciting cause, and when the 
patient is quiet, but they are commonly induced by those causes which 
we have already mentioned as aggravating the symptoms of cyanosis. 
They come on suddenly, and are attended by increase of lividity, disten- 
sion of the jugulars, and sometimes of the cutaneous veins, and by a sen- 
sation of present suffocation. They last only a few minutes, and are suc- 
ceeded by great depression of the vital powers. In infants, on account 
of greater nervous irritability, and feeble power of endurance, these par- 
oxysms often end in convulsions, which occasionally are fatal. A cough 
is sometimes present, but is usually slight. 

Pain is not a common symptom. Some of the patients complain occa- 
sionally of headache, with or without vertigo, and occasionally also of 
pain in the chest, but it is uncertain to what extent or whether these 
symptoms are dependent on the cyanotic disease. The secretions do not 
appear to be affected, so far as has been ascertained. The same may be 
said of the intellectual and moral faculties. In a case related by Dr. 
Chevers, the child was even said to be precocious. (Lond. Med. Gaz. T 
vol. xxxviii.) The mind is capable of steady application and acquisition^ 
as in health, provided that the emotions are not unduly excited. 

Those who are affected with cyanosis are liable to various forms of 
haemorrhage, but this liability, if we may judge from recorded cases, is 
greater in youth and adult life than in infancy. In two cases blood was 
vomited, in one passed by stool, in one it escaped from the gums, in two 
from the mouth, in eight from the nostrils, and in sixteen it was expec- 
torated. Pulmonary phthisis was, however, usually present in these last 
cases. In the Western Journal of Medicine for 1829, an interesting case 
is related by Dr. Wm. M. Yoris of a girl, nine years old, in whom haem- 
orrhage occurred under the scalp, producing great tumefaction, and nearly 
closing the eyelids. An incision was made, from which a pint and a half 
of dark blood escaped, and it was estimated that more than half a gallon 
was lost during the ensuing two weeks, at the expiration of which time 
the incision closed. The patient recovered from the haemorrhage, but 
not from the cyanosis. 



PROGNOSIS. 803 

Toward the close of life more or less anasarca occasionally occurs, 
especially around the ankles, sometimes in the eyelids and face, and rarely 
to a certain extent over the whole body. In certain patients it coexists 
with effusion in the serous cavities. 

It is evident that one who is affected with the severer form of cyanosis 
is disqualified for the duties of active life. The sports of childhood and 
the useful labors of mature years require an exertion for which he is phys- 
ically unfit. He has not the ability even to engage in animated con- 
versation, for he is overcome by emotions, whether of joy or sorrow. 
He lives almost an idle spectator of the world around him, prevented by 
his infirmity from engaging in its pursuits. 

Intercurrent diseases, especially those of childhood, are badly tol- 
erated ; but hooping-cough is the one which these patient are especially 
ill-fitted to endure. Still, they sometimes pass safely, not only through 
hooping-cough, but through some of the most dangerous febrile diseases. 
It is a question of interest, but about which little is known with cer- 
tainty, whether these intercurrent maladies are influenced by the cyanotic 
or venous condition of the blood. The symptoms of these maladies are 
no doubt more alarming, mainly on account of the embarrassed action of 
the heart, and not on account of the state of the blood ; still it is rea- 
sonable to suppose that malignant and asthenic diseases are rendered 
worse by the lack of oxygen, and excess of carbonic acid in the circulat- 
ing fluid. 

Probably cyanosis does not furnish immunity from any other disease, 
although this statement has been made by a high authority. Rokitansky 
says : " All forms of cyanosis, or rather all the diseases of the heart, great 
vessels, and lungs, adapted to produce cyanosis, in a greater or less degree, 
cannot coexist with tuberculosis. Cyanosis affords a complete protection 
against it, and in this circumstance may be found an explanation of the 
immunity from tuberculosis which many conditions of the system, appar- 
ently very different in their character, afford.'' 1 (Handb. der Pathol. 
Anat. II. Bd.) This opinion of the distinguished pathologist, notwith- 
standing his ample opportunities for observation and known accuracy as 
an observer, is not substantiated by statistics. So far from its being true, 
the low degree of vitality in cyanosis appears to favor the occurrence of 
tubercles. I have records of twenty-six cases of cyanosis in which tuber- 
culosis was also present, in several of which the lungs contained cavities. 
This is about thirteen per cent of the whole number in my collection — a 
large proportion, since so many die in early infancy, at which period the 
tubercular disease is not apt to occur. Cyanosis appears, also, to favor 
the development of cerebral diseases, especially congestion and coma, as 
will be seen presently. 

Prognosis. — This is unfavorable. Most cyanotic individuals die 
young. The age which they attain has been made the subject of statis- 



804 CYANOSIS. 

tical inquiry by Aberle. He states that in an aggregate of 159 cases, 57, 
or 35 per cent, died before the end of the first year ; 108, or more than 
two thirds, died before the age of eleven years ; 30 between the ages of 
eleven and twenty-five years ; and of the remaining 21, only 5 lived more 
than forty-five years. 

The age at which death occurred, is given, in 186 of the cases collect- 
ed by myself, as follows : 

In 17 under the age of 1 week. In 21 from 5 years to 10 years. 



" 10 frc 


m 1 week to 1 month. 


" 41 " 10 ' 


1 « 20 


" 12 ' 


' 1 month to 3 months. 


" 20 " 20 « 


i « 40 


u U < 


' 3 months to 6 months. 


" 4 over 40 ' 




" 17 ' 


' 6 " to 12 " 







" 12 < 


' 1 year to 2 years, 


186 




" 21 ' 


' 2 years to 5 " 







Sixty-seven, then, or more than one third, died before the close of the 
first year ; 121, or more than three fifths, before the age of ten years ; 
only 24 survived the age of twenty years, and four the age of forty years. 
Of course, the duration of life depends on the nature and extent of the 
malformations. Some of these are such as render a speedy death inevit- 
able. 

Mode of Death. — The mode of death is recorded in ninety-five cases, 
as follows : 

19 died in a paroxysm of dyspnoea. 

suddenly (the exact manner not stated). 

in convulsions (infants). 

of apoplexy. 

from haemorrhage. 

of phthisis (though, as we have seen, twenty others had this 

disease). 
of exhaustion, without haemorrhage, 
of coma, 
of abscesses in the brain. 

One died of each of the following diseases : cerebral irritation, conges- 
tion of brain, effusion in the cranial cavity, acute hydrocephalus, paraly- 
sis from acute softening of the brain, dysentery, inflammation of heart, 
syncope, mucus in the air-passages, thoracic inflammation, choleraic diar- 
rhoea, pneumonitis, bronchitis, scarlet fever, croup. One died in trying 
to walk, one after a spasmodic cough in pertussis, one after a long 
agony, one after an agony of ten or eleven hours ; one is recorded to 
have died gradually, and three quietly. 

The ten who are stated to have died suddenly probably died in parox- 
ysms of palpitation and dyspnoea, which, we have seen, are easily excited, 



10 


<( 


14 


<( 


2 


a 


7 


n 


6 


a 


2 


<( 


10 


it 


2 


a 



MODE OF DEATH. 805 

and of common occurrence in cyanosis. If so this was the mode of death 
in 29 cases. Infants, with few exceptions, so far as appears from the 
records, died in convulsions. Nineteen died of cerebral affections, exclu- 
sive of convulsions, and in thirteen of these the cause of death was con- 
gestion, apoplexy, or coma. The haemorrhage of which seven died was 
probably, in most instances, dependent on phthisis, and six are said to 
have died directly of phthisis. We may, then, regard paroxysms of pal- 
pitation and dyspnoea, convulsions, congestive affections of the brain, and 
phthisis, as common modes or causes of death in cyanosis. 

The malformations of the heart and great vessels which give rise to 
cyanosis are quite numerous. The following table exhibits their charac- 
ter and relative frequency : 



1. Pulmonary artery absent, rudimentary, impervious, or partially obstructed, 97 

2. Right auriculo- ventricular orifice impervious or contracted, ... 5 

3. Orifice of the pulmonary artery, and the right auriculo-ventricular aper- 

ture impervious or contracted, 6 

4. Right ventricle divided into two cavities by a supernumerary septum, . 11 

5. One auricle and one ventricle, ........ 12 

6. Two auricles and one ventricle, ........ 4 

7. A single auriculo-ventricular opening ; inter-auricular and inter-ventric- 

ular septa incomplete, 1 

8. Mitral orifice closed or contracted, 3 

9. Aorta absent, rudimentary, impervious, or partially obstructed, . . 3 

10. Aortic and the left-auriculo-ventricular orifices impervious or contracted, 1 

11. Aorta and pulmonary artery transposed, . 14 

12. The cavae entering the left auricle, 1 

13. Pulmonary veins opening into the right auricle or into the cavse or azygos 

veins, 2 

14. Aorta impervious or contracted above its point of union with the ductus 

arteriosus ; pulmonary artery wholly or in part supplying blood to the 
descending aorta through the ductus arteriosus, .... 2 

Total, 162 

From the above table it appears that in more than one half of the cases 
of cyanosis the congenital vice which gives rise to it is located in the pul- 
monary artery. It is located also, in general, in that part of the artery 
which is nearest the heart. Its character is different in different cases. 
Sometimes there is an arrested development of this vessel, and in its 
place we find simply a ligamentous cord extending from the heart as far 
as the ductus arteriosis, while beyond this point the artery and its 
branches are pervious ; rarely the entire artery is ligamentous, and of 
course impervious ; in other cases this vessel is open through its 
whole extent, but the part nearest the heart is so small as to be properly 
considered rudimentary ; in others still there is adhesion of the valves to 
each other as the chief congenital defect, and, finally, in rare instances 
the obstruction in the pulmonary artery is due to an adventitious mem- 



806 CYANOSIS. 

brane ? which stretches across the vessel like a diaphragm. These last 
malformations, namely, adhesion of the valves and the formation of an 
adventitious membrane, are doubtless due to inflammation occurring in 
the artery before birth, and some attribute the arrested development 
and ligamentous state of the vessel to the same cause. 

In most cases of cyanosis, due to obstructive malformations, the inter- 
auricular and inter-ventricular septa are more or less deficient. This defi- 
ciency obviously results from the obstruction, for the septa are formed in 
the heart after foetal circulation is established, and the blood, being pre- 
vented by the vicious formation from flowing in its proper channel, neces- 
sarily passes to the opposite side of the heart. More or less blood being 
forced from one auricle or one ventricle to the opposite cavity, it is evi- 
dent that a permanent aperture must result in the septum. The aperture 
in the septum ventriculorum is ordinarily at its base ; in the septum auric- 
ulorum it corresponds with the foramen ovale. 

In most of the obstructive malformations one and rarely two abnormal 
cardiac murmurs have been observed. The single murmur accompanies 
the ventricular contraction. As it has been observed in cases of complete 
as well as incomplete obstruction, it seems to be due mainly to the flow 
of blood through the apertures in the septa. 

Modes of Compensation. — In most cases of cyanosis the congenital 
defect is partially obviated by modes of compensation. In the most fre- 
quent malformation, that in which there is obstruction in the pulmonary 
artery, and a considerable part if not all the blood flows directly from the 
right to the left side of the heart, the ductus arteriosus not only remains 
open, but is greatly enlarged, through which a current of blood enters the 
pulmonary artery from the aorta, and passing to the lungs is oxygenated. 
The bronchial arteries have also been found greatly enlarged, and it is be- 
lieved that though they are the nutrient arteries of the lungs, the blood 
which they convey to these organs is decarbonized in its circuit through 
them. In a case published by Mr. Le Gros Clark, in the Medico- Chir. 
Trans. , vol. xxx. , the bronchial arteries were not only enlarged, but a 
" branch from the internal mammary artery, which accompanied the 
phrenic nerve, was nearly equal in size to the parent trunk, and expended 
itself principally in the adjacent adherent lung." Branches of the inter- 
costal arteries have also been found enlarged, and entering the lungs, or 
connecting with vessels which enter the lungs. By such modes of com- 
pensation cyanosis is rendered milder, and life is prolonged. To these we 
must attribute the fact that some have very considerable malformation, 
and yet do not become cyanotic. 

Morbid Anatomy.- — This, as regards the circulatory system, has been 
sufficiently dwelt upon. No chemical analysis, so far as I am aware, has 
yet been made of cyanotic blood. We know that it is dark, its coagula- 
bility feeble, that it contains an excess of carbonic acid, and is deficient 



MORBID ANATOMY. 807 

in oxygen. From the nature of cyanosis, it would be inferred that in 
many cases there is a degree of passive congestion in the cavities of the 
heart, and consequently in the capillaries of the systemic system, giving 
rise to more or less serous effusion. Statistics show that this is so. The 
•quantity of pericardial fluid is in some patients increased. I have records 
relating to this fluid in fifty-one cases. Usually it was pure serum. In 
seventeen the quantity was half an ounce or less, if we include in the 
number those in which the amount is expressed in such terms as ' ' due 
quantity, " " usual amount," and " small amount." In twenty-four 
cases the pericardial fluid (serum) exceeded half an ounce, usually esti- 
mated at from one to six ounces, but in two it exceeded the latter quantity. 
In one of the twenty-four this fluid was stained with blood. In two 
patients the records state that there was a small quantity of pure blood in 
the pericardium, and in one the two pericardial surfaces were agglutinated 
by inflammation. 

In some of the autopsies serum was found in the pleural cavities, 
usually in connection with pericardial effusion, and in at least one in- 
stance this fluid was tinged with blood. Old adhesions between the cos- 
tal and pulmonary pleura were observed in a few instances. The condi- 
tion o£ the lungs was recorded with more or less minuteness in one hun- 
dred and ten cases. Mention has already been made of the large number 
affected with tubercular disease, which was either confined to the luno-s, 
or was chiefly exhibited in these organs. In thirty-five patients the 
records state that the lungs were of small size, either by compression, or 
sometimes, apparently, from the continuance of the foetal state over a 
greater or less portion of the organ. The compression was produced 
either by the distended pericardium or by effusion in the pleural cavities. 
In thirty -five cases the lungs presented a dark color. This hue in some 
specimens accompanied the unexpanded or fcetal state of the organ, but 
in others there was the normal inflation, and the dark color was due to 
engorgement or congestion. In other cases the lungs are stated to have 
been natural, except the color. In nine emphysema was present in a part 
of the lungs, in two pneumonitis ; in two the color of the lungs was pale, in 
one a bright crimson ; in one the lungs were larger than natural, in one 
the right lung was absent, and in seventeen these organs were recorded 
healthy. 

I have records of the state of the liver in twenty-six cases, in sixteen of 
which it was enlarged, and in four of these it was congested. Congestion 
•of the liver was present in eight other cases, in which no mention is made 
of its volume. The parenchyma of this organ had a natural appearance in 
nine cases, but in some of these there was enlargement. From these sta- 
tistics it is probable that the liver is commonly enlarged in cyanosis, and 
not infrequently congested. In a few cases the condition of the other 
.abdominal viscera is mentioned ; in some as healthy, in others as congested. 



808 CYANOSIS. 

Fifteen examinations of the brain were made, in seven of which conges- 
tion is recorded, and in three abscesses in the cerebral substance, in one of 
which cases the lateral ventricle was also filled with pus ; in two softening 
of a portion of the brain had occurred, in three the brain was firm or com- 
pact, in three the quantity of fluid in the cranial cavity exceeded the 
normal amount, and in one it was less than normal. 

Theories Relating to the Etiology of Cyanosis. — Although in 
nearly all cyanotic patients there are direct communications between the 
two sides of the heart, it is shown by many observations that these com- 
munications or apertures are not sufficient in themselves to produce 
cyanosis. This opinion was expressed half a century ago by Louis, who 
published an excellent monograph on the subject of these communica- 
tions, basing his remarks on an analysis of twenty cases. Since the pub- 
lication of this paper, the belief has been pretty general in the profession, 
and observations continue to substantiate it, that, although the apertures 
may be of considerable size, if the two sides of the heart, with their 
orifices and vessels, are in their normal state, so that they act symmetri- 
cally and without obstruction, cyanosis will not occur. In proof of the 
correctness of this opinion many cases might be cited of a pervious, and 
some of a largely dilated foramen ovale, without the cyanotic hue, cases 
which have been published in the journals since the appearance of Louis's 
monograph. Still, in cases of obstructive malformation, unless the ob- 
struction be complete, cyanosis is more apt to occur in consequence of 
these apertures, for were they absent a larger amount of blood would be 
propelled through the narrowed orifice, and a larger amount consequently 
be oxygenated. 

Allusion has already been made to the two theories which prevail in 
the profession ; the one attributing cyanosis to the intermingling of ve- 
nous and arterial blood ; the other to obstruction at the centre of circula- 
tion, and consequent venous congestion. There are serious objections to 
the acceptance of either theory as an explanation for all cases. That ad- 
mixture of the two kinds of blood is not essential to the production of 
cyanosis, is apparent from the following facts. In one case in the Fourth 
Malformation, there was no communication between the two sides of the- 
heart, and the ductus arteriosus was closed, so that admixture was impos- 
sible. Again, in the Eleventh Malformation, or that in which the aorta 
and pulmonary artery are transposed, the blue disease evidently does not 
depend on the admixture of the two currents. On the other hand, in this 
curious state of the heart, the more the admixture the less the cyanosis, 
since the only way in which the systemic current of blood can be arterial- 
ized is by passing to the opposite side of the heart. An argument against 
this doctrine may also be found in the fact that the modes of compensa- 
tion are not such as in any way diminish or obviate the admixture. It is 
admitted that in the more frequent malformations cyanosis is increased by 



ETIOLOGY OF CYANOSIS. 809 

the apertures, which allow the intermingling of the venous and arterial cur- 
rents, but it is more reasonable to consider the intermingling and the 
cyanosis as the direct results of the malformation, neither having the pre- 
cedence of the other, than to consider that they are related to each other 
as cause and effect, or as proximate and remote results. Viewed in this 
light, the admixture must be considered simply a concomitant of the 
cyanosis. 

The second theory, that of venous congestion, has numbered among its 
advocates many who have given special attention to the subject, as Mor- 
gagni, Louis, and Stille, but it seems to have even less claim for accept- 
ance than the theory of admixture. It has been seen that in nearly all 
cases of cyanosis the two sides of the heart communicate freely, so that if 
the current of blood meet with an obstruction, as it commonly does, it 
readily escapes to the opposite side where the artery is large and gives it 
free passage. In this way congestion, if no prevented, is greatly dimin- 
ished. Again, it will be seen that, although certain of the viscera are fre- 
quently found at the autopsy more or less congested, congestion is not 
uniformly present in the organs, as it would probably be were it the prox- 
imate cause in all cases of cyanosis. 

Moreover, in some patients the malformation is not obstructive. The 
cavities and their orifices are of the normal size, and cyanosis is due 
entirely to malposition of the vessels. It cannot be said that in these cases- 
there is venous congestion from arrest at the centre of circulation. If 
there be any congestion, it must be due to the fact that venous blood does- 
not circulate as readily as the arterial in the capillaries. It is true that 
in the paroxysms of dyspnoea there is sometimes more or less congestion ; 
the distension of the jugulars show this, but it subsides with the parox- 
ysms, and it probably is no more than usually occurs when the respiration 
is greatly embarrassed 

In fine, attempts to express the immediate pathological state producing 
cyanosis in the terms of a general law have failed. However plausible 
the above theories may appear in regard to certain cases, there are others 
to which they are manifestly inapplicable. Those who advocate these 
theories seem to lose sight of the obvious fact that the chief want of the 
economy in cyanosis is decarbonization of the blood, and it is hardly sup- 
posable that there can be any correct theory of its causation which is not 
founded on this fact. With this physiological state in view, it does not 
seem difficult to express a theory in comprehensive terms which is applica- 
ble to all cases, such as the following : Cyanosis is due to vices or defects 
in the organism, usually congenital, which prevent the free and regular 
flow of blood to, through, or from the lungs. So comprehensive a state- 
ment includes not only cases of malformation and malposition of the heart 
and its vessels, but also those few cases in which the lungs are in fault. 
In most patients, as we have seen, the current of blood toward the lungs 



810 CYANOSIS. 

is obstructed, and the current of blood from the lungs, in those compara- 
tively rare cases in which the malformation is on the left side. 

Treatment. — From the nature of cyanosis it is evident that the treat- 
ment should be more hygienic than medicinal. The patient should be 
warmly clad and kept in a warm room, and all agencies calculated to em- 
barrass or disturb the functions of the body or excite the emotions, and 
thereby accelerate the heart's action, should be studiously avoided. The 
diet should be nutritious, but simple and easily digested. 

Those who have attributed cyanosis wholly to apertures in the inter- 
auricular and inter-ventricular septa, and the consequent flow of blood 
from the right to the left side of the heart, have considered it an impor- 
tant part of the treatment to keep the patient reclining on the right side, 
so as to diminish this flow by the effect of gravitation. The reader, how- 
ever, must be convinced from the nature of the malformations that little 
benefit can accrue from following such advice. Still, patients are some- 
times less cyanotic and more comfortable in one position than another. 
In a case reported by Mr. Howship (Edin. Med. Jour., 1813), " the only 
easy and indeed comfortable position in which the child could remain 
was that usual in nursing. When erect, the dusky color of the face and 
neck became a dark -blue. " In a case related by Mr. Spackman (Lond. 
Med. Gaz., 1833), the patient was easiest on the hands and knees. Louis 
reports a case (de la Commun. des Cav., etc.) in which the selected posi- 
tion was with the head elevated ; Wm. Hunter a case {Med. Obs. and 
Enq., vol. vi.) in which the patient avoided paroxysms by lying on the 
left side. Struthers and King each report a case in which the patients 
seemed most comfortable while lying on the right side (Monthly Jour, of 
Med. Sci.), while, on the other hand, Professor White, of Buffalo (Buf. 
Med. Jour., 1855), and Dr. Jas. Carson (Amer. Jour, of Med. Sci., 1857), 
report cases in which position on the right side failed to produce any 
alleviation of symptoms. Other similar observations might be cited, but 
enough have been mentioned to show that no one position should be 
recommended for cyanotic patients. Some obtain most relief by lying 
on the back, others on the right side, others on the left, some when on 
the hands and knees, some when reclining on either sike indifferently, 
while, finally, others suffer least when erect. 

There was a time when the paroxysms were treated by venesection, but 
depletion has long since been abandoned. Physicians now rely on stim- 
ulants, antispasmodics, friction to the chest, and mustard pediluvia, to 
relieve the urgent symptoms, although this treatment is but partially suc- 
cessful. It is probable that of all internal remedies digitalis is the most 
useful, from the fact that it is an efficient heart tonic, and more than any 
other medicine gives strength and equality to the heart beats. In the cities 
where oxygen gas can be procured for daily inhalation, it seems not im- 
probable that the urgent symptoms might in some instances be partially 
relieved by the use of this agent. 



SECTION Y. 

SKIN DISEASES. 



CHAPTER I. 

EKYTHEMATOUS DISEASES. 

Under this head are included erythema, roseola, and urticaria. They 
consist in an active congestion, inflammatory it is believed, of the skin, 
which soon declines, with or without slight furfuraceous desquamation. 
The color of the affected cuticle is bright-red in erythema, rosy in rose- 
ola, and pale-red in urticaria. Febrile symptoms often precede for a few 
hours the occurrence of the eruption, and they abate as it appears. 

Erythema. 

The eruption of erythema occurs in patches of different sizes, the larg- 
est ordinarily not exceeding four or five inches in length, and most of 
them have considerably smaller dimensions, their margins being in some 
instances diffused, and in others circumscribed and well defined. The 
patches are slightly swollen from engorgement of the capillaries of the 
skin and slight serous effusion, and are accompanied by a sensation of 
heat and itching. 

Erythema is idiopathic or symptomatic. The idiopathic form is subdi- 
vided into erythema simplex, intertrigo, and laeve. Erythema simplex is 
produced by external agencies of an irritating nature, as heat, cold, fric- 
tion, chemical and mechanical irritants, applied to the skin. A common 
example of this form of the disease is the efflorescence about the anus in 
cases of infantile diarrhoea due to acidity of the evacuations. Erythema 
intertrigo is produced by the friction of opposing surfaces of the skin, 
and it therefore occurs mainly in the folds of the neck, about the groins, 
and behind the ears. This inflammation is sometimes slight, disappear- 
ing in two or three days with proper treatment ; in other cases the epi- 
dermis becomes denuded, the surface is tender and moist, and even 
superficial excoriations occur. In severe cases the ulcers extend more 



812 ERYTHEMA. 

deeply and give rise to considerable purulent discharge, the skin and even 
subcutaneous connective tissue being more or less infiltrated and indu- 
rated. The confinement of the perspiration, and the moisture, which is 
exuded between the folds of the skin, increase the inflammation. The 
effused liquid does not in ordinary cases stiffen linen, as in eczema. Ery- 
thema laeve is the name applied to the inflammatory hyperemia of the 
skin, which often occurs over cedematous parts. Its most common seat is 
about the ankles and upon the legs. In children it is most frequently 
observed in the oedema which results from scarlatinous nephritis and from 
heart disease. 

Symptomatic erythema, which results from a general or constitutional 
cause of a pyrexial character, has several subdivisions. The simplest and 
mildest form of it is erythema fugax, which comes and goes quickly. 
The erythema which occurs upon the features in acute meningitis is a 
typical example. It is common in various inflammatory and febrile affec- 
tions. If the erythematous patch be circular, with normal skin in its cen- 
tre, it is sometimes designated erythema circinatum, and, if the margin be 
well defined, marginatum. Erythema papulatum, tuberculatum, and 
nodosum are applied to the same form of the disease, one or the other 
term being employed according to the stage or size of the eruption. In 
erythema papulatum the eruption begins as small red spots, which soon 
become papular, and attain a size varying from that of a pin's head to a 
split pea. It occurs especially on the neck, breast, arm, and back of the 
hand, and fades away, with a slight desquamation, in about three weeks. 
In erythema tuberculatum and nodosum the eruptions have a greater 
diameter, and are usually more prominent. In the latter variety they 
often have a diameter of two or more inches, and occur most frequently 
upon the anterior aspect of the leg. These three forms of erythema, 
which might be described as one, occur chiefly in young people. Ery- 
thema tuberculatum is most common in servants, especially those recently 
from the country. The tumefaction is due to the effusion of serum in 
the corium, and, when the eruption has considerable prominence, also in 
the subcutaneous connective tissue. The color is at first a bright-red, 
then dark-red or purple, and it fades away like the discoloration of a 
bruise as the eruption declines. Rheumatism is often and diarrhoea occa- 
sionally associated with these forms of erythema, and rheumatic pains are 
occasionally present, as well as more or less febrile movement. 

Prognosis. — This, as regards the erythema, is always good. An un- 
favorable result in any case is due to cachexia, or some coexisting 
disease. The duration of the milder cases is only a few hours, while 
those of a more severe type, as erythema nodosum, last two or three weeks. 

Diagnosis. — The ordinary forms of erythema are distinguished from 
erysipelas, by the absence of any very decided burning pain, and tume- 
faction of the integument, and tendency to spread, and by less marked 



TREATMENT. 813 

constitutional symptoms. In those cases of erythema in which there is 
infiltration and swelling of the skin and subcutaneous connective tissue, 
the patches are distinguished from those of erysipelas by being multiple, 
of smaller size, less hot and painful, not extending, and presenting as they 
disappear the phenomena of a bruise. In urticaria the wheals that come 
and go suddenly with a peculiar stinging sensation, and the irritability of 
the skin in consequence of which these wheals are produced by slight 
friction, differ so much from the symptoms and appearances of erythema 
that the differential diagnosis of the two is easy. In roseola the eruption 
ordinarily occurs over a large part, if not the entire surface, in points and 
small patches with healthy skin between, and presenting a rosy instead of 
a bright-red color, characters which sufficiently distinguish it from ery- 
thema. Erythema when extensive is sometimes mistaken for the scarlati- 
nous eruption, but the redness of the fauces, graver constitutional symp- 
toms, vomiting, persistence of the eruption, etc., serve to distinguish the 
latter from the former affection. In cases of doubt it is proper to defer 
the diagnosis for a day or two, when if the rash be erythematous it will 
fade. Erythema sometimes occurs in the initial stage of variola, when, 
on account of the grave general symptoms, it may be mistaken for scarla- 
tina. I have more than once known this mistake to be made in the hur- 
ried visit of the physician. A more careful examination would prevent 
this error. There is little danger of confounding erythema with measles, 
or the various papular, vesicular, or pustular skin diseases. 

Treatment. — Erythema fugax requires no special treatment, unless 
occasional dusting the surface with lycopodium or powdered starch. 
These forms of erythema which are due to mechanical or chemical irritants 
soon disappear when the cause is removed. In erythema around the 
anus, produced by the irritation of the urinary andalvine evacuations, the 
diaper should be changed as soon as soiled, and if the stools be frequent 
and acid, the alkaline treatment proper for the diarrhoea is useful also for 
the erythema. In inflammation from this cause as well as in erythema 
intertrigo, the following prescriptions for external use will be found 

beneficial : 

B. Bismuthi subnitrat., 3j ; 
Glyceriti amyli, 3j. Misce. 

B. Lycopodii, 1 ss ; 

Pulv. bismuthi subnitratis, 1 iss. Misce. 

B. Pulv. zinc, oxid., 

Lycopodii, aa 1], Misce. 
To be frequently dusted upon the inflamed surface. It is better to apply vaseline 
first, and dust upon this. 

B. Zinci oxid., 3 ij ; 
Glycerinae, 3 ij ; 
Liq. plumb, subacetatis, 3 iss ; 
Aquae calcis, I vj to viij. Misce. 



814 ROSEOLA. 

In obstinate cases a weak solution of nitrate of silver, sulphate of cop- 
per, or better, as it does not stain the linen, sulphate of zinc, will fre- 
quently be followed by immediate improvement. 

B. Zinci sulphat., gr. vj ; 
Glycerinae, § ij ; 
Aq. rosse, § iv. Misce. 
To be constantly applied between the folds of the skin on linen. 

Potassium chlorate, internally, to correct the acidity of the transpiration 
from the skin in protracted and obstinate cases, and in certain instances 
cod-liver oil and the syrup of iodide of iron, are called for. If the de- 
rangement of the system upon which the erythema depends appear to be 
of a rheumatic character, colchicum or alkalies may be required. Ery- 
thema papulatum, tuberculatum, and nodosum occur most frequently in 
reduced states of the system, and therefore need tonics. 

Roseola. 

The term roseola is applied to rose-colored spots or patches of greater 
or less extent, accompanied by a degree of febrile reaction, and often by 
redness, with little or no swelling of the faucial surface. It is attended 
by a sensation of warmth and slight itching. The following groups and 
subdivisions embrace the recognized varieties of this disease : 

Roseola. 
Idiopathic. Symptomatic* 

Infantilis. Variolosa. 

^Estiva. Vaccinia. 

Autumnalis. Miliaris. 

Annulata. Rheumatica. 

Punctata. Arthritica. 

Cholerica. 

Febris continues. 

Syphilitica. 

The color of the eruption gradually fades from a rose-red to a duller 
hue, and often disappears in two or three days. In other instances the 
eruption lasts a week or more. Roseola may occur in any season, but it 
is most common, especially the idiopathic form, in the warm months* 
Those varieties of the idiopathic disease which are designated infantilis, 
sestiva, and autumnalis are the most common in early life. They are in 
reality identical, or nearly so, and may be described as one disease. 

Symptoms. — Roseola infantilis, sestiva, or autumnalis may be partial, 
appearing upon the arms, and legs, or general. It is often preceded by 



CAUSES — PROGNOSIS — DIAGNOSIS. 815 

febrile movement, languor, and in those old enough to describe their 
sensations, pain in head, back, and limbs. There is great difference, 
however, in different cases as regards the severity of the prodromic 
symptoms. They may be absent or so slight as scarcely to be appreci- 
able. Occasionally vomiting, diarrhoea, or other symptoms of derange- 
ment of the digestive apparatus immediately precede the eruption. 

The eruption of roseola, when general, usually commences upon or 
about the neck and face, and in the course of twenty-four to thirty-six 
hours appears upon the rest of the surface. It bears considerable resem- 
blance to that of measles. The patches are irregular in shape, a quarter 
to half an inch in diameter, and, though of a rose color at first, they soon 
present a dusky hue as they begin to fade ; by pressure the redness dis- 
appears. In the majority of cases the eruption has nearly faded by the 
fifth day. The redness of the faucial surface, together with the itching 
or tingling, disappears with the subsidence of the rash. 

Roseola annulata is a rare disease. It commences with constitutional 
symptoms, which are slight or pretty severe, and which cease when the 
eruption appears, this occurs in the form of red circular spots, which 
enlarge to the diameter of an inch or thereabout and assume the shape of 
rings inclosing healthy skin. The rash fades in a few days, often leaving 
a bruised appearance. The ordinary location of this form of erythema is 
upon the abdomen, and about the thighs. In roseola punctata the erup- 
tion is of small size, and it occurs upon a large part of the surface. 

Symptomatic roseola, which appears in the course of various diseases, 
need only be alluded to. The diseases in which it is developed are, with 
the exception of syphilis, chiefly of an acute febrile or inflammatory char- 
acter. This eruption is often really, as stated by Tilbury Fox, a rose- 
colored erythema, but in other instances it presents the typical form and 
appearance of roseola. Thus I have known it to occur about the eighth 
or ninth day of vaccinia in rose-colored spots over the whole surface, 
and producing much anxiety on the part of parents, lest impure virus had 
been employed. 

Causes. — These are in a measure obscure. The delicacy of the skin in 
infancy and the active cutaneous circulation no doubt predispose to rose- 
ola and erythema, and hence the frequency of their occurrence in acute 
febrile and inflammatory affections. Summer weather, with the derange- 
ments of system which it produces, has been in my experience much the 
most frequent cause of idiopathic roseola in young children in this city. 
In certain summers, as in that of 1868, a large proportion of the infants 
have been affected by it, and I have been led to consider it a favorable 
prognostic sign as regards the diarrhceal affections which are so common 
in the warm months. 

Prognosis. — Roseola is always a mild and favorable disease. 

Diagnosis. — Roseola is distinguished from jLeasles, by the absence of 



816 URTICARIA. 

catarrhal symptoms, a less degree of fever, less uniformity in the size of 
the eruption, and the absence of any history of contagion. Roseola is 
distinguished from erythema by the smaller size of the eruption and its 
rosy or dusky red color. The boundary line, however, between the two 
diseases is not well defined, and certain forms of roseola might be de- 
scribed as erythema. The general but punctiform efflorescence, increase 
of temperature, acceleration of pulse, and the peculiar appearance of the 
tongue and fauces, serve to distinguish scarlet fever from roseola. There 
is little danger of confounding roseola with urticaria, since the wheals of 
the latter appear in no other disease. 

Treatment. — This is simple. If roseola occur in connection with gas- 
trointestinal derangement or disease, the remedies which relieve the lat- 
ter exert a curative effect upon the former. In all cases the state of the 
system should be inquired into, and any departure from a state of health 
corrected. Roseola needs no farther constitutional treatment. If there 
be itching or tingling of the surface, a lukewarm lotion, containing equal 
parts of liq. ammon. acetat. and mistura camphorse, has been recom- 
mended, or a lotion containing a drachm of hydrocyanic acid to a pint of 
an emulsion of bitter almonds, used warm. The purpose of such lotions 
is simply to relieve the unpleasant sensation. Cold applications, or others 
which would repel the eruption, should be avoided ; such an effect might 
be injurious. In cases of acidity of stomach alkaline remedies are useful, 
and in certain cases tonic treatment is indicated. 



Urticaria. 

The name by which this disease is designated is derived from the term 
urtica, the nettle, the sting of which produces this form of eruption. 
The eruption occurs suddenly in wheals or pomphi, attended by tingling 
and burning, and suddenly disappearing. Urticaria is ofteD accompanied 
by no very decided general symptoms, but in other cases there are febrile 
movement, and lassitude, with perhaps epigastric pain and headache. 
The wheals may occur over the whole body, but more frequently are con- 
fined to a portion of it. Their shape may be round, oval, irregular, or 
band-like, and their length varies from a few lines to several inches. In 
one affected by urticaria the wheals can be readily produced by scratching 
or rubbing the surface. The eruption is thus clearly described by a 
recent writer : "At first a bright flush appears, the centre of this becomes 
slightly elevated, and pales, hence appears of lighter color ; the tint may 
be rosy, but more generally it is whitish." The margin of the wheal, the 
diameter of which varies, always remains red. This eruption appears to 
be produced by active congestion of the cutaneous capillaries, some serous 
effusion, and spasm of the muscular fibres of the skin. The effusion of 
serum in certain localities is quite apparent from the oedema which occurs. 



PAPULAR DISEASES. 817 

The subsidence of the eruption is without desquamation. Urticaria is 
ordinarily an acute disease. It is sometimes chronic in the adult, but 
rarely so in children. Several varieties of it are described by dermatolo- 
gists, according to the cause, appearance, and duration. 

Causes. — These are external and internal. Various irritants apart 
from the nettle applied to the surface produce the wheals, as the bites of 
certain insects and sometimes turpentine. The following are the princi- 
pal internal causes, as summarized by Hillier : 1st, profound and sudden 
mental emotion ; 2d, certain articles of diet, as shell-fish, pork, sausage, 
cheese, etc. ; 3d, certain medicinal substances, as copaiba, valerian, and 
turpentine ; 4th, intestinal worms, though it is probable that these seldom 
operate as a cause ; 5th, uterine ailments, as hysteria. 

Prognosis — Diagnosis. — The prognosis is good, though the chronic 
form is sometimes tedious and troublesome. The occurrence of the 
wheals and the possibility of producing them by friction serve to distin- 
guish this disease from all others. 

Treatment. — In urticaria due to any recent ingesta of an irritating or 
indigestible character, an emetic of ipecacuanha is useful, followed by a 
saline, and better also alkaline aperient, as Rochelle salts. An aperient of 
this character is useful ordinarily in acute cases, attended by febrile reac- 
tion. The diet for several days should be simple, and such as is readily 
digested, as fresh beef, bread, or other farinaceous food, and milk. Oc- 
casionally the wheals appear periodically, when a few doses of quinine 
effect a prompt cure. After the above measures have been employed, the 
subsequent treatment, whether tonic or otherwise, depends on the condi- 
tion of the patient. Little benefit accrues from local measures. Spong- 
ing the surface with cool water to which a little vinegar is added relieves, 
in a measure, the heat and tingling of the wheals. 



CHAPTER II. 

PAPULAR DISEASES. 

STROPHULUS. 

The three papulae, namely, lichen, prurigo, and strophulus, which are 
characterized by small and firm elevations upon the skin, occur in chil- 
dren ; but the two former are not common, and, as they do not differ in 
any essential particular from the same diseases in the adult, they will not 
be treated of in this connection. Strophulus, on the other hand, is a dis- 
ease peculiar to children. It is known as the red gum or white gum, 
according to its appearance, and also as the tooth rash. This eruption 
52 



818 PAPULAR DISEASES. 

appears usually on parts which are exposed, as the face, neck, and ex- 
tremities, the papules being in some patients of the size of, or even 
smaller than, a pin's head, while in other cases they are as large as a 
millet-seed. 

The varieties of strophulus described by dermatologists are : 

S. intertinctus. S. candidus. 

" confertus. " volaticus. 

" albidus. " pruriginosus. 

The following are the characters of these varieties : S. intertinctus,. 
papules bright red, and occurring chiefly upon the cheeks, forearm, and 
back of hand ; often inter tinctured with blushes of erythema ; it lasts 
from two to four weeks, and is most common in young infants. S. con- 
fertus, papules numerous, and closely aggregated, paler, continuing longer 
than in strophulus intertinctus, and likely to recur, appearing about the 
time of dentition, and most frequently upon the arm. Sometimes certain 
of the patches become chronic, slowly disappearing, and leaving the skin 
rough and dry. S. volaticus appears usually upon the arms and cheeks 
in patches of about a dozen, fewer or more, papules, which soon disap- 
pear. These patches reappear at intervals for two or three weeks, and 
are attended by heat and itching, though not intense. S. albidus, so 
called, should really be placed among the diseases of the sebaceous glands, 
and described under another name. It appears in the form of small white 
elevations as large as a pin's head, commonly upon the face and neck, and 
produced by distension of the sebaceous glands with the secreted product. 
The term strophulus candidus is applied to large whitish papules, which 
appear upon the sides of the trunk, shoulders, and arms of infants of one 
year or thereabouts, and disappear in about one week. They are apt to 
be associated with the papules of strophulus confertus. S. pruriginosus 
is really a form of lichen, occurring chiefly over the age of one, and under 
that of eight or nine years. The papules, which are small and discrete, 
usually appear over a large extent of surface, ordinarily upon the back, 
front of the chest, the face and arms, and, as they are scratched from the 
itching, minute dark points of blood collect and dry upon their apices. 
This form of strophulus is more protracted than the others, and, in conse- 
quence of the irritation produced by the scratching, pustules of ecthyma 
often occur among the papules. The apparent cause of strophulus pru- 
riginosus is a mode of life which impoverishes and vitiates the blood, 
such as uncleanliness, residence in damp, dark, overheated, and over- 
crowded apartments. Atmospheric heat also operates as a cause, and it 
is a not infrequent disease in the cities during the summer months. 

The various eruptions included under the term, strophulus have such 
different anatomical characters, that a proper classification would locate 
some of them in other groups of skin diseases*. One form of it, as we 



ECZEMA. 819 

have seen, is produced by distension of the sebaceous glands ; in other, 
and the majority of cases, as appears from the recent observations of Mr. 
Fox, its seat is the sweat glands, and in others still the papillary layer of 
the skin, as in lichen, the papules being produced by an exudation. 

Treatment. — Personal cleanliness, with frequent change of linen, and 
daily ablution without the use of soap, should be enjoined. Local irri- 
tants, which might aggravate or cause the disease, should, so far as prac- 
ticable, be removed. Alkalies in cases of acidity of the primce vice, and 
occasionally mild aperients, are required ; the food should be bland, but 
nutritious, and if the child be nursing, it may be necessary to attend to 
the health of the wet-nurse. Favorable hygienic conditions, important for 
the successful treatment of all forms of strophulus, are especially required 
in strophulus pruriginosus. Nutritious diet, fresh air, quinine, iron, cod- 
liver oil, etc., should be prescribed for those affected by it. The follow- 
ing formula is recommended for sponging the surface in cases of strophu- 
lus : 

I£. Sodii carbonat., 3j ; 
Glycerinae, 3 ij ; 
Aq. rosae, §vj. Misce. 



CHAPTER III 



ECZEMA. 

This is one of the most common maladies of the skin. It constituted one 
third of Devergie's cases, and one sixth of Hillier's. In the commence- 
ment of the eczematous eruption the skin presents a superficial redness, 
and upon this inflamed area numerous minute and closely aggregated 
papules, vesicles, or, more rarely, pustules, soon appear. These are very 
fragile, so that they soon rupture, the epidermis is broken and destroyed, 
and the surface is moistened by an effusion which appears to be serum, 
and cannot be distinguished from it by the microscope. This liquid when 
dry stiffens linen. As it dries thin crusts form, of a light yellow color, in 
most localities, but thicker, and of a deeper yellow color upon the scalp. 
The crusts consist mainly of pus, epithelial cells, and granular matter. 

Anatomy. — Biesiadecki has described the formation of the eczematous 
eruption. According to him the papules are produced from the papillce, 
which increase in size by cell formation in their interior. The connec- 
tive-tissue corpuscles enlarge, and are unusually " rich in fluid," and 
their number increases. Under the microscope spindle-shaped corpuscles 
are observed, filling the papillae, and extending up from them into the 
rete Malpighii, crowding apart the cells of this layer, and reaching and 



820 ECZEMA. 

elevating the epidermis. The epithelial cells in the immediate vicinity of 
the papillae also become swollen. This cell-growth produces the eczema- 
tous papule. 

If the cell formation continues within a papilla, certain of the cells are 
ruptured, and as they are very moist a liquid is effused, which raises the 
epidermis over the summit of the papilla. This produces the eczematous 
vesicle. Occasionally pus mixes with this liquid, and the eruption is then 
vesico-pustular. 

In acute eczema the upper part of the true skin is infiltrated and 
swollen, while the lower part is commonly unaffected, except in the most 
severe cases. The older the eczema the greater the extent of the infiltra- 
tion, so that in chronic eczema the whole thickness of the skin is more 
apt to be involved than in acute forms of the malady. The discharge of 
the eczematous surface is irritating, and healthy skin, with which it may 
come in contact, is often reddened by it and made eczematous, from its 
irritating effect. This eczema occurring upon a part of the surface which 
is in contact with an opposite surface of sound skin, commonly affects the 
latter, and as Neumann has stated, a nurse, by carrying an infant having 
eczema upon its nates, may contract the same disease upon her arm, 
although there is no contagious principle in this malady. 

Etiology. — Eczema is often produced by irritating substances applied 
to the skin. Croton oil, certain soaps, the finger nails in scratching, a 
hat, truss, or belt, by pressure may produce it. Those having a tender 
and delicate skin are more liable to it than others. The constitutional 
causes are often obscure. It is sometimes obviously due to indigestion, 
or a diet which disagrees, for we see it occur in nursing infants as a re- 
sult of sickness of the mother. Anaemia and scrofula are occasional 
causes. Among the city poor eczema is common, and many of the chil- 
dren who have it are scrofulous, but a large proportion show no evidence 
of struma, and in the better classes of society a majority do not. 

Varieties — Symptoms — Course. — Eczema is sometimes designated 
according to its location as E. faciei, capitis, etc. Another designation, 
which has more scientific value, is according to the form and stage of the 
eruption, by which we have the following recognized varieties, to wit : 
Eczema papulosum, vesiculosum, pustulosum, rubrum, impetiginosum, 
and squamosum. A simpler and still more convenient classification is into 
eczema simplex, rubrum, impetiginosum, and squamosum. 

Eczema of the scalp is common in infancy, occurring as an eczema ru- 
brum or impetiginosum. The eczematous exudation mingling with the 
secretion of the sebaceous glands, which are numerous upon the scalp, 
forms a thick yellow crust. It is apt to extend beyond the hairy portion 
to the forehead and around the ears. This extension aids in establishing 
the diagnosis between eczema and certain other cutaneous eruptions of 
the scalp. Eczema of the external ear is sometimes primary, but in 



DIAGNOSIS. 821 

other instances it is consecutive to that of the scalp, and due to the exten- 
sion of the latter. Its common seat is in the angle behind the ear, and 
upon the lobe of the ear, whence it often extends along the auditory 
meatus, narrowing its calibre, and impairing the hearing temporarily, or 
even for years. Eczema upon the forehead commonly occurs in children 
from extension of the eruption from the scalp. The cheeks, lips, and 
chin are often also affected by eczema, which in this situation is com- 
monly eczema rubrum, and is attended by redness, swelling, and trouble- 
some itching. The swollen and red appearance with the crusts and marks 
produced by scratching often greatly disfigure the countenance. In chil- 
dren, when eczema occurs upon other parts, it is usually associated with 
that of the scalp, face, or ears — that in the latter situations being the 
most severe and obstinate. 

Eczema simplex is common in the summer months, being produced by 
the heat of the atmosphere, aided perhaps by other causes. The patient 
may appear well, or be somewhat indisposed, having febrile symptoms, 
and soon an erythematous patch of greater or less extent appears, upon 
which a cluster of the characteristic papules or vesicles soon occurs. 
These break, forming slight crusts, which are detached, and the eczema 
declines, or it may continue longer, with successive crops of the eruption. 

In eczema rubrum, since it is a more severe form of the disease, the 
febrile movement and the local symptoms are greater than in the preced- 
ing variety, and the eczematous patch presents the appearance of a more 
intense inflammation. The papules or vesicles are often so minute as to 
be with difficulty recognized. They are soon broken, when they form 
with the secretion and exudation from the surface yellowish or brownish- 
yellow scabs. The discharge is more irritating, as it is more abundant 
than in eczema simplex, and the adjacent skin is usually more inflamed 
from its contact. 

Eczema impetiginodes is common in young debilitated children, in 
whom, in consequence of the cachexia, inflammations, of whatever char- 
acter, are apt to be suppurative. This form of eczema presents at first 
the symptoms and features of eczema rubrum, but the transparent liquid 
of the vesicles soon becomes opaque, from the generation and admixture 
of pus-corpuscles. The crusts, which form from the rupture and desicca- 
tion of the vesiculo-pustular eruptions, are thick and greenish-yellow, and 
in infants the sebaceous glands, which are involved in the inflammation, 
pour out an abundant secretion, increasing the thickness of the crusts. 
This form of eczema is most common in infancy, and its usual seat is 
upon the scalp. 

Diagnosis. — Eczema presents in different instances so different an ap- 
pearance that it is not always readily diagnosticated. It will aid in its 
diagnosis to recollect that it is in its nature a catarrh, affecting primarily 
and chiefly the upper portion of the derma and the Malpighian layer, 



822 ECZEMA. 

and although it may now present a dry or scaly appearance (E. squa- 
mosum), yet its history will show that there has been a discharge or 
moisture. In a large proportion of cases, the physician is not able to 
detect papules or vesicles, since they are fragile and transient, breaking 
in the first thirty-six hours, and not reappearing. Still, when they are 
absent, we sometimes observe around the margin of the patch an appear- 
ance which indicates that they have been there. Their minuteness is 
occasionally such that they may escape notice, on a cursory inspection, 
when they are present and well defined. Acute eczema, affecting a con- 
siderable extent of surface, is often attended by febrile movement, and 
might be mistaken for one of the eruptive fevers, but the absence of cer- 
tain distinctive appearances, which characterize these fevers, and the 
speedy appearance of the eruption and moisture, establish the diagnosis. 
Eczema can be readily diagnosticated from ordinary erythema, which is a 
superficial inflammation without moisture. The location of erythema in- 
tertrigo serves for its diagnosis, as it is evidently produced by the attri- 
tion of opposite surfaces of the skin. Moreover it lacks the elevated pa- 
pillae, and the discharge does not stiffen linen like that of eczema. Lichen, 
when acute, presents some resemblance to eczema, but it is dry and pap- 
ular, the papules, though small, being detected by the finger as well as 
sight. The large and irregular phlyctenule, intense inflammation and 
cedenia, and mode of extension of erysipelas ; large, scattered, and non- 
inflammatory vesicles of sudamina ; scattered and acuminate vesicles, 
without surrounding inflammation, of scabies ; are so different from the 
eczematous eruption that the differential diagnosis is readily made. 
Herpes circinatus can be distinguished from eczema by its circular shape, 
larger size, and greater permanence of the vesicles, and the delicate, 
branny scales, which consist rather of epithelial cells than the product of 
exudation as in eczema. 

Treatment.* — Every case of eczema should be cured as quickly as pos- 
sible, as we know that there is no danger of any other disease arising 
from too rapid cure of any skin affection, and also know that a long-con- 
tinued eczema may not only seriously interfere with the general health of 
a child from the constant irritation and restlessness which it produces, 
but also that from the cutaneous irritation the neighboring lymphatic 
glands may become inflamed and undergo a caseous degeneration, which 
in turn can produce a tubercular formation in the lungs or meninges. 
The treatment of eczema is both local and constitutional. Some cases do 
well with local treatment alone, but in the majority internal treatment is 
of great assistance, even when we are unable to detect any dyscrasia or 
special condition of the blood or general system. If any special dyscrasia 
be present, as scrofula, etc. , then the child must be treated with the appro- 

* Revised by Dr. A. R. Robinson, of the Dermatological Society. 



TREATMENT. 823 

priate agents for this in addition to the means employed against the ecze- 
ma. No one line of treatment is suitable for every case, and therefore a 
large number of remedies have been used and recommended. Among 
the city poor strumous cases are common, and cases also in which without 
any pronounced diathetic state the cause is apparently a reduced state of 
the system from innutritious diet and other anti-hygienic conditions. 
Such cases require better diet and a mode of life more in accordance with 
sanitary requirements. On the other hand, I have observed cases of 
eczema which seemed to be produced by a plethoric state of the system in 
the nursing infant, when the milk of the mother or wet-nurse was un- 
usually rich and abundant. While, therefore, ill-nourished and weakly 
children require better regimen, with perhaps vegetable and ferruginous 
tonics, the plethoric require reducing treatment, though of a gentle kind. 
For the latter the following prescription will be found useful : 

B. Pulv. rhei, 3 ss ; 
Sodii bicarb., 3 j ; 

Aquae menth. piperita?, 1 iv. Misce. 
Dose, one teaspoonf ul three or four times a day for a child of two years of age. 

In such cases also, an occasional purgative dose of calomel has been 
recommended by some dermatologists. In addition to measures designed 
to meet the special indications of a case, there is one internal remedy, 
arsenic, which has been found of signal benefit, whatever may have been 
the fault of system from which the eruption originated. As I have stated 
in the chapter relating to therapeutics, children tolerate arsenic much bet- 
ter than adults do, consequently it can be given to them in larger propor- 
tionate doses. A most useful combination is that of arsenic with alkaline 
diuretics, as the latter exert a marked beneficial influence upon eczema, 
frequently not inferior to that of arsenic. In fact, at the commencement 
of an acute eczema, it is better to give the alkaline diuretics alone, and, 
later in the disease, when there is less redness and irritation of the skin, 
to combine the arsenic with them. The dose of the latter is to be regu- 
lated according to its effect upon the child and also upon the eruption. 
Always give as large a dose as the child will bear well, so as to obtain the 
best results from its action. The following formula is for a child one 

year old : 

B. Potassii acetatis, 3 iss ; 

Liq. potassii arsenitis, gtt. xxiv ; 
Spits, etheris nitrosi, 3 ij ; 
Syrupi aurantii, 3 vj ; 
Aqua? carui, 9, s. ad. § iij. Misce. 
Dose, one teaspoonful three times a day. 

If the arsenic produce intestinal irritation, paregoric should be added 
to it. 

Local Treatment. — This varies according to the condition of the skin 



824: ECZEMA. 

at the seat of the eruption. In all cases of acute eczema with irritable- 
skin, soothing applications must be employed, and not irritating salves. 
The part should not be washed with water, as it irritates and aggravates 
the eruption. When the surface is red, angry-looking, and discharging 
a thin watery secretion, lead or alkaline lotions are useful, as the fol- 
lowing : 

#. Liq. plumbi subacet., f j ; 

Glycerini, 

Aquae, aa "% iv. Misce. 
To be applied two to four times a day with a camel's-hair pencil. 

One of the most useful applications for the treatment of acute eczema in 
children is a salve made of equal parts of vaseline and simple lead plaster. 
If this proportion be too strong for an individual case, it can be made 
milder by increasing the amount of vaseline. It should be applied twice 
a day by spreading it either on linen or waxed paper. Sometimes the 
oxide of zinc ointment answers very well for the early stages of the dis- 
ease. The ointment of the pharmacopoeia is, however, generally too 
strong, so that it may irritate — five grains to the ounce of simple salve 
being frequently strong enough. Sometimes the part is so tender that 
only a dusting powder can be used to protect the surface from the air 
while internal treatment is employed. When the discharge has become 
thicker and more purulent, and forms scabs, the above-mentioned oint- 
ments are to be used. If the scabs are very thick they can be removed 
by soaking the part with oil and washing once with soap and water. In. 
eczema of the scalp, if the hair be long it should be cut as short as possi- 
ble, otherwise a salve cannot be applied with any benefit. When the 
eruption has arrived at that stage when almost all discharge has ceased, 
and the surface is simply hyperaemic, with more or less branny scales,, 
some tar preparation should be used. These remove the last traces of the 
eruption, and stop the itching which is present. * They are to be used as 
long as any itching or trace of the disease is present, since, until they 
both disappear, there is danger of a return of the eruption to an acute 
condition. The oil of cade can be used of full strength or diluted with 
alcohol or mixed with cod-liver oil to any desired extent. It must be s 
well rubbed into the part, and applied about once a day. In eczema ru- 
brum situated in the flexures of the joints, we have obtained good results 
by the constant wearing of a solid rubber bandage on the part until 
cured. If the eczema occupy a large portion of the surface of the body, 
then it is advisable to endeavor to cure the eruption by the internal use of 
the potash and arsenic mixture given above, combined or not, according 
to the effect produced, with alkaline or bran baths. In cases of inter- 

* The Sisters in the New YoTk Foundling Asylum employ the tar soap in 
these cases, with, they state, an almost uniform good result. 



SCABIES. 825 

trigo, either the lead lotion can be used or the part kept as dry as possi- 
ble with lycopodium powder, to which can be added some snbcarbonate 
of bismuth. Flannel should on no account be worn next the inflamed 
surface, since woollen material irritates and keeps up the eruption. On 
account of this irritating action it should not be worn next the skin after 
the eruption has disappeared, lest it might cause a return of the disease. 
The following formulae have been recommended by dermatologists. 
For internal use ; 

B. Vim ferri (Br. Ph.), §iss; 
Syrup tolutan. , 3 iij ; 
Liq. potassii arsenit., 3 j ; 
Aq. anethi, fij. Misce. 
Recommended by E. Wilson. Half a teaspoonful may be given three times 
daily to an infant of one year. 

B. 01. morrhuae, fij; 
Vitel. ovi no i ; 
Liq. sodii arseniat., 3 j ; 
Syrupi, 3 ij ; 
Aquae, fiv. 
Half a teaspoonful three times daily to an infant of one year. 

External. — The prescriptions recommended on a preceding page for 
erythema intertrigo are useful for many cases of eczema : 

B. Picis liquidae, 3 ij ; 

Potassae, 3j ; 

Aquae, 3 v. Misce. (Bulkley.) 
The quantity of water may be doubled for children. 
B. Bismuthi subnitrat., 3 ij ; 

Glycerini, §j. Misce. {Pardee.) 

Scabies. 

The diseases of the skin previously considered are non-contagious. 
Scabies, on the other hand, is one of the most contagious diseases by 
contact. It is produced by an animal parasite, known as the itch-mite, 
or acarus scabiei. The inflammation is caused by the female only, which 
burrows, making for itself a canal, or cuniculus, in which its eggs are de- 
posited. The male does not burrow, but conceals itself under the scales 
or crusts which result from the inflammation produced by its partner, or 
it burrows only sufficiently to produce a covering and shelter. From ob- 
servations made by Eichstedt, Gudden, and others, the female has been 
found within half an hour after being placed upon the skin to have con- 
cealed herself in the epidermis, and the burrow which she constructs is 
arched and tortuous, and four or five lines in length, shorter or longer. 
The acarus has the shape of a tortoise. It can when fully grown be de- 
tected by the eye as a minute whitish point. The young acarus has six, 
the mature eight, articulated legs, with suckers upon the two anterior 



326 



SCABIES. 



pairs, and hairs on the posterior. The head, which can be elongated or 
retracted, is provided with two jaws. The upper surface is covered with 
spines directed backward so as to prevent retrogression in the burrow. 
She leaves behind her in the cuniculus, as she advances, her moulted skin, 
excreta, and eggs, which hatch on the eleventh day. The mother acarus 
is always found at the remote end of the burrow, where it can be seen by 
the unassisted eye as a minute whitish or sometimes brownish speck, and 
from which it can he lifted by the point of a needle to which it clings. 



Fig. 27. 




Fig. 28. 




Fig. 30. 








Fig. 29. 




Fig. 27. The itch animalcule, acarus,scabiei, viewed upon the back, showing its figure and the 
arrangement of its spines and filaments. The female, which is somewhat larger than the male, 
has a length of l-80th to l-60th of an inch. 

Fig. 28. The foot and last joints of the leg of the itch animalcule. 

Fig. 29. The male itch animalcule, viewed upon the under surface, showing its legs and tabu- 
lated feet. 

Fig. 30. Ova of the itch animalcule. 

The cuniculi can also be seen by the naked eye, looking, says Niemeyer, 
like the " scars of needle scratches/' and containing the young acari in 
various stages of growth. 

The acarus by its burrowing produces an irritation and troublesome 
itching, which is the chief cause of the suffering of the patient. At the 
point where the acarus penetrates the cuticle the inflammation gives rise 
"to a single, small, and acuminate vesicular or papular eruption, the cuni- 
culus extending away from it. We often find ecthymatous pustules and 
abrasions intermingled with the vesicles, the result of the frequent scratch- 
ing. The itching is most intense, and the acarus most active, at night, 
when the patient is warm in bed. Scabies most frequently appears, es- 
pecially in adults, first upon the hands, between the fingers, where the 
skin is thin, and it extends thence along the forearm, and over the thighs 
and abdomen. In children it not infrequently occurs upon the buttocks, 
thighs, feet, etc., while the hands and forearm escape. 

X)iagnosis. — Correct diagnosis is important, because the treatment re- 



TREATMENT 827 

quired is different from that in any other exanthem, and because the sus- 
picion of having this disease always renders one solicitous to know the 
exact nature of the eruption. Scabies can be diagnosticated from those 
diseases for which it might be mistaken by the following characters : its 
occurrence where the cuticle is thin and delicate, as between the fingers, 
along the anterior aspect of the forearm, upon the abdomen, thighs, and 
inside of the feet ; small size, acuminate shape, and isolated position of 
vesicles ; the intermingling with the vesicles of other forms of eruption, as 
papules and pustules, and the presence of linear scars and abrasions pro- 
duced by the scratching ; itching most intense at night ; absence of 
fever ; absence of the disease from posterior aspect of body and arms, and 
from head and face. Scabies may be distinguished by the vesicular charac- 
ter of the eruption from all other cxanthematic affections except eczema, 
sudamina, and herpes. Eczema is most common on the scalp and face, 
where scabies does not occur, and unlike scabies its vesicles are round and 
thickly aggregated in clusters ; in eczema there is a smarting or prickling 
sensation very different from the intense itching of scabies. In herpes 
the vesicles are large, rounded, and in clusters, and attended by a burn- 
ing or pricking sensation, with but little itching. The eruption in suda- 
mina is vesicular and discrete, as in scabies, but it is globular, and accom- 
panied by no itching or other local symptoms. 

Treatment. — As scabies is due to a species of acarus which burrows 
in the epidermis, it can only be treated successfully by measures which 
destroy this animalcule. If it be destroyed, the disease gets well of itself. 
Sulphur has been employed for a long period for this purpose, since sul- 
phurous acid, which is evolved from the sulphur, is destructive to the ani- 
malcule. The unguentum sulphur! s, if thoroughly applied, will rarely 
fail to eradicate scabies. The internal use of sulphur aids the external 
treatment, since a portion of the gas which is generated escapes through 
the pores of the skin. The chief objection to the employment of sulphur 
is its exceedingly unpleasant odor, which is noticeable, however disguised 
by perfume. Sulphur or any other substance employed externally has 
more effect if it be preceded by a bath, which softens the epidermis, and 
therefore favors the entrance of the remedy into the pores of the skin and 
the cuniculi. 

Helmerich's ointment is very effectual in the treatment of scabies. It 
consists of two parts of sulphur, one of carbonate of potassium, and eight of 
lard. " M. Hardy afterward perfected the method, so as radically to 
cure the disease in two hours. He proceeded in the following manner : 
The patient first undergoes a friction of his whole body for half an hour 
with soft soap, in order to cleanse the skin and break up the burrows ; a 
warm bath of an hour's duration follows, during which the skin is 
thoroughly rubbed, in order to complete the destruction of the burrows ; 
after which frictions for half an hour and upon the whole surface are 



828 SCABIES. 

practised with Helmerich's ointment. This completes the cure. Out of 
four hundred patients subjected to this treatment, only four returned to 
the hospital." (Stille's Therapeutics, etc., vol. ii. p. 516.) 

M. Albin Gras experimented with different substances, in order to as- 
certain their relative destructiveness to the acarus. The following table 
gives some of the results of his experiments : 

Immersed in pure water the acarus was alive after three hours. 

" saline water the acarus moved freely after three hours. 

" Goulard's solution the acarus lived after one hour. 

" olive, almond, or castor oil the acarus lived more than two hours. 

" lime-water the acarus died in three-fourths of an hour. 

" vinegar " " twenty minutes. 

alcohol 
" turpentine " " nine " 

" iodide of potassium the acarus died in four to six minutes. 

It is seen that vinegar, lime-water, alcohol, turpentine, and iodide of 
potassium destroy the acarus in a short time. They may be employed in 
the same manner as the sulphur ointment. Camphor is also destructive 
to this animalcule, and the linimentum camphorse, thoroughly applied, is 
a good remedy for uncomplicated scabies. 

In order to avoid the odor of sulphur, whicn is so offensive, one of the 
following ointments may be employed, if the patient be fastidious : 

]£. Unguent, hydrarg. ammoniat., f j; 
Moschi, gr. ij ; 
01. lavendul., gtt. ij ; 
01. amygdal., 3j. Misce. (From Wilson.) 

If scabies be extensive this should not be used, as its application over 
considerable area might endanger salivation, but the following, which is 
recommended by Bazin, and is said to cure the disease with three appli- 
cations, may be used instead : 

9- Anthemis pulv., 
Adipis, 
01. olivse, aa Ij. Misce. 

In cases which have been protracted, and in which ecthymatous and 
other secondary eruptions have occurred, the scabies can ordinarily be 
readily cured, while the other eruptions remain and disappear more 
slowly. A knowledge of this is important, since the sulphur, or other 
ointment employed for the cure of scabies, should be discontinued 
when the itching ceases and vesicles no longer appear, and tonic, or other 
treatment appropriate to cure these secondary eruptions, should be em- 
ployed instead. The sulphur ointment continued, after the scabies is 
cured, does harm, as it irritates the cuticle. It is essential in the treat- 
ment of scabies that the linen be frequently changed. 



INDEX 



ACEPHALUS, 377 
anatomical characters, 377 
symptoms, prognosis, 378 
Allin, Dr. C. M.,on retro-pharyngeal ab- 
scess, 662 
Apncea neonati, 74 
causes, 74 
treatment, 74, 75 
Artificial feeding, 61 
Ascaris lumbricoides, 745 
Asphyxia neonati, 74 
Atelectasis, 569 
acquired, 569 
anatomical characters, symptoms, 

571 
treatment, 572 

BARKER, Prof. Fordyce, on the use of 
turpeth mineral in croup, 548 
Bathing, 68 
Bigelow, Dr. W. S., cases of diphtheria, 

248 
Blue disease, 793 
Bothriocephalus latus, 751 
Brain in infancy and childhood, 376 

absence of, 377 
Brain, imperfect, 379 

case, 379 

symptoms, prognosis, 380 

atrophy of, 380 
Brain, hypertrophy of, pathological an- 
atomy, 382 

nature of, 383 

symptoms, case, 384 

diagnosis, 385 

prognosis, treatment, 386 
Brain, congestion of, 391 

causes, 392 

symptoms, anatomical characters, 
prognosis, 394 

treatment, 395 
Brain, haemorrhage in and upon, 396 
Brain, dropsy of, acquired, 412 

congenital, 406 
Bronchitis, 556 

causes, anatomical characters, 557 

symptoms, 560 

diagnosis, prognosis, 563 

treatment, 564 



Bulkley, Dr. L. D., on dactylitis syphi- 
litica, 174 

Byrd, Prof. H. L., on mode of resuscita- 
tion, 76 

pANCRUM oris, 643 

\J Cancer, aqueous, of infants, 643 

Caput succedaneum, 76 

Caries, vertebral, 523 

Case, deformity of child from injury of 

mother, 23 
Cephalaernatoma, 76 
Cerebro-spinal fever, 328 
cause, 330 

its non-contagiousness. 331 
sex, 333 

age, symptoms, 334 
cases, 335 

mode of commencement, 336 
symptoms pertaining to the nervous 

system, 337 
digestive system, 339 
pulse, 340 
temperature, 341 

respiratory system, cutaneous sys- 
tem, 342 
organs of special senses, the eye 

and ear, 344-346 
nature, 346 
prognosis, 348 
diagnosis, 350 
anatomical characters, 351 
treatment, preventive, curative, 355 
Cerebro spinal meningitis, 328 
Cerebro-spinal system, diseases of, 375 
Chadbourne, Dr., on quantity of food re- 
quired, 56, 57, 58 
instrument for performing thora- 
centesis, 520 
Chapman, Dr. E. M., on alcoholic stimu- 
lants in diphtheria, 285 
Chicken-pox, 246 
Childhood, 19 

changes of organs in, 19 
Cholera infantum, causes, 721 
symptoms, 722 
anatomical characters, 723 
nature, cases, 724, 725 
diagnosis, prognosis, 726 



830 



INDEX . 



Cholera infantum — 

treatment, 727 
Chorea, 481 

age, 482 

causes, sex, 483 

uterine irritation, anaemia, rheuma- 
tism, 484 

embolism, 486 

case, 487, 488 

fright, irritation, 489 

intestinal irritation, lesions of spi- 
nal cord, 489 

anatomical characters, 491 

symptoms, 492 

prognosis, course, 494 

diagnosis, treatment, 495 
Church, Dr. A. S., case of intussuscep- 
tion, 784 
Circulatory system, 94 

change from foetal to infantile, 18 
Clothing, 69 

Colitis in childhood, 718 
Colostrum, 34 

constituents of, 35 
Congestion of stomach, 674 
Constipation, 728 

symptomatic ; causes, congenital 
stenosis, 729 

intestinal displacement, 729 

obstructive substances, abscesses, 
tumors, peritonitis, 730 

idiopathic ; diseases of the cerebro- 
spinal system, 732 

causes, 732 

symptoms, 734 

treatment, 738 

hygienic measures, 739 

therapeutic measures, 742 
Consumption (see Tuberculosis), 143 
Convulsions, clonic, 442 
Convulsions, internal, 473 

causes, 474 

anatomical characters, symptoms, 
476 

case, 477 

diagnosis, 478 

prognosis, mode of death, treat- 
ment, 479 
Coryza, 529 

anatomical characters, symptoms, 
prognosis, 530 

treatment, 531 
Cough, nervous, treatment, 630 
Cranial sinuses, thrombosis in, 387 
Craniotabes, 111 
Croup, false, spasmodic, 535 

true, pseudo-membranous, 540 
Cyanosis, 793 

its literature, 794 

sex, causes of the malformation, 796 

time of the commencement, 798 

symptoms, 799 

prognosis, 803 

mode of death, 804 

nature of the malformations, 805 



Cyanosis — 

modes of compensation, morbid! 

anatomy, 806 
theories relating to the etiology of 

cyanosis, 808 
treatment, 810 

DACTYLITIS, scrofulous, 127 
Dalton, Prof. John C, effect of ma- 
ternal emotions on the foetus, 
22 
quantity of food required, 60 
Deformity of child from injury to 

mother, 23 
Delafield, Prof. Francis, dissection of 

rachitic case, 103 
Dentition, 650 

pathological results from, 651 
diagnosis, treatment, 654 
second dentition, 657 
Diagnosis of infantile diseases, 89 

features, appearance of head, trunk,. 

and limbs in disease, 89 
attitude, movements, voice, 91 
Diarrhoea.. 685 

symptoms, 686 
anatomical characters, 687 
prognosis, treatment, 688 
Diet a cause of infantile mortality, 28 
quantity of food required, 55 
artificial, 61 
Digestion, post-mortem, 680 
Digestive apparatus, diseases of, 632 
Digestive system, its state as a means 

of diagnosis, 98 
Diphtheria, 248 
age, 248 
incubation, 249 
nature, 250 

bacteria as a cause, 252 
facts showing its constitutional na- 
ture, 256-260 
anatomical characters, 260 
Prof. Rindfleisch's views, 262 
cases, 263-268 
symptoms, 272 

of invasion, 273 
respiratory apparatus, 274 
diphtheritic croup, 275 
kidneys, 376 
paralysis, 276 
diagnosis, 278 
prognosis, 279 
causes of death, 279 
treatment, 281 
stimulants, 285 
local treatment, 288 
the use of the atomizer, 289 
general treatment, 286-289 
diphtheritic croup, 289 
its treatment, 292,293 
preventive measures, 294r 
Dress, 69 

Duchenne's disease, 511 
Dyspepsia, 669 



INDEX 



831 



ECLAMPSIA, 442 
causes, 443 

premonitory stage, 444 
symptoms, 445 
partial eclampsia, 446 
anatomical characters, 447 
diagnosis, 448 
prognosis, treatment, 450 
Eczema, anatomy, 819 

etiology, varieties, symptoms, 

course, 820 
simplex, rubrum, impetiginoides, 

821 
diagnosis, 821 
treatment, 822 
Elliot, Prof. George S., case of peri- 
pharyngeal abscess, 662 
Entero-colitis of infancy, 690 
Enteritis in childhood, colitis in child- 
hood, 718 
cause, symptoms, 718 
diagnosis, prognosis, treatment, 
719 
Erysipelas, 361 

table of cases, 366, 367 

age, point of commencement, causes, 

368 
vaccination as a cause, 369 
erysipelas of the new-born, 370 
premonitory symptoms, symptoms, 

371 
prognosis, 372 

duratioD, modes of death, patho- 
logical anatomy, 373 
treatment, 374 
Erythema, 811 

idiopathic, 811 

symptomatic, prognosis, diagnosis, 

812 
treatment, 813 
Ewing, Dr., case of diphtheria, 249 
Exercise, 72 

FACIAL paralysis, 510 
Feeding, artificial, 54, 61 
Feeding, improper, a cause of infantile 

mortality, 28 
Fever, cerebrospinal, 328 
Fever, intermittent, 313 
Fever and ague, 313 
remittent, 318 
typhoid, 320 
Flint, Prof. A., Jr., on diet of infants, 

27-64 
Flint, Prof. A., Sr., 233 
Fcetus, how affected by the state of the 
mother in pregnancy, 20 

GALACTORRHEA, its treatment, 47 
Gangrene of the mouth, 643 
Gangrene, anatomical characters, 643 
age, causes, 644 
symptoms, 645 
diagnosis, 646 
prognosis, treatment, 647 



Gastritis, 675 

cause, age, 676> 

case, symptoms, 677 

anatomical characters, diagnosis,, 

prognosis, 678 
treatment, 679 
Gastritis, follicular, diphtheritic, 679, 

680 
Gastro-intestinal haemorrhage, 762 
German measles, 216 
Gilfillan, Dr., on the use of the castor 

oil plant as a galactogogue, 47 
Glottic spasms, 473 

Greuning, Dr., experiments upon the 
auditory nerve in cerebro-spinal fever, 
346 
Growth of infants, 29 

HEMORRHAGE, umbilical, 85 
Haemorrhage, intra-cranial (men- 
ingeal, cerebral), 396 
causes, 396 

anatomical characters, 397 
cerebral, 399 
symptoms, 400 
capillary form, 402 
symptoms in meningeal haemor- 
rhage, 403 
diagnosis, prognosis, 404 
treatment, 405 
Haemorrhage, gastro-intestinal, 762 
three varieties, 1st variety, 762 
2d variety, 764 
3d variety, 765 
prognosis, treatment, 766 
Hall, Prof., case of unnatural lactation, 

44 
Hammond, Prof. Wm. A., on maternal 

emotions, 22 
Hassell, Dr., on mode of preparing Lie- 
big's food, 65 
Hawley's Liebig's food, 65, 66 
Heitzman, Dr., microscopic examination 

of a case of diphtheria, 263 
Heitzman, Dr. D. S., on the etiology of 

rachitis, 107 
Hooping cough, 295 
Horlick's Liebig's food, 65 
Hydrocephalus, acquired, causes, 413 
anatomical characters, symptoms, 

414 
case, 415 

prognosis, treatment, 416 
Hydrocephalus, congenital, anatomical 
characters, 406 
cases, 407-409 
symptoms, 410 

diagnosis, prognosis, treatment, 412: 
Hydrocephalus, spurious, 437 

anatomical characters, case, 437 
symptoms, 438 
cases, 439-441 
diagnosis, 441 
treatment, 442 
Hydrocephaloid: disease, 437/ 



832 



INDEX. 



TCTERUS neonati, 87-89 
J- Imagination, 769 
Indigestion, causes, 669 

symptoms, 670 

prognosis, treatment, 672 
Infancy, 17 

skin and sebaceous glands in, 17 

organs in, 18 

stomach in, 18 

kidneys in, 18 

mental faculties in, 18 

brain in, 18 
Infantile paralysis, 498 
Intermittent fever, 313 

in what way contracted, period of 
incubation, 314 

symptoms, 315 

treatment, 317 
Intestinal worms, 744 
Intestines, inflammation of, in infancy, 
690 

causes, 691 

dietetic, atmospheric, 692-698 

dentition as a cause, 698 

age, 699 

symptoms, 700 

anatomical characters, 702 

diagnosis, prognosis, 708 

treatment, 709 
Intussusception, without symptoms, 768 

with symptoms, previous health, 
cases, 769 

sex, age, 770 

seat, pathological anatomy, intus- 
susception in small intestine, 
771 

cases, 772, 773 

in large intestine, 775 

symptoms, 777 

diagnosis, 779 

duration, 780 

prognosis, 781 

mode of death, treatment, 783 

cases, 784-787 

laparotomy by Dr. Jonathan Hutch- 
inson, 790 

laparotomy by Dr. Henry B. Sands, 
791 

JACKSON, Dr. James, on second den- 
tition, 657 
Jacobi, Prof. A., case of craniotabes, 103 
Jacobi, Prof. A., on infant diet, 64 
Jacobi, Dr Mary P., on infant diet, 64 
Jacobi, Prof. A., statistics of tracheoto- 
my, 551 
Jaundice in the new-born, 87-89 
Jenkins, Dr. J. Foster, on umbilical 
haemorrhage, 86 

KERATITIS, 138 
Knapp, Prof. , on the state of the 
ear in cerebro-spinal fever, 346 
Krackowizer, Dr. Ernst, statistics of 
tracheotomy, 552 



LACTATION, 29 
mode of determining capability 

for, 29 
hindrances to, 30 
tender nipples, 31 
ill-health of mother, 31 
syphilis, 32 
inflammations, 33 
suppuration of breast, 33 
erysipelas in mother, 33 
course of, 52 
weaning, 52 
Laparotomy, by Dr. Jonathan Hutchin- 
son, 790 
by Dr. Henry B. Sands, 791 
Laryngismus stridulus, 473 
Laryngitis, catarrhal, symptoms, 532 
chronic, 533 

anatomical characters, treatment, 
534 
Laryngitis, spasmodic, causes, symp- 
toms, 535 
anatomical character, pathology, 

536 
diagnosis, 537 
prognosis, treatment, 538 
Laryngitis, pseudo-membranous, 540 
causes, anatomical characters, 541 
symptoms, 544 
pathological characters, diagnosis, 

546 
prognosis, treatment, 547 
tracheotomy, 551-556 
Learning, Dr. J. R., case of erysipelas, 

370 
Liebig's food, 65 

Livingston, Dr. W. C, case of peripha- 
ryngeal abscess, 667 
Lockjaw, 453 
Lung, collapse, 569 
Lung, inflammation of, 573 

MEASLES, German, 216 
Measles, 178 
Measles, symptoms, 178 
complications, 181 
anatomical characters, nature, 184 
diagnosis, prognosis, treatment, 185 
Meningeal haemorrhage, 396 
Meningitis, tubercular and non-tuber- 
cular, 417 
age, pathological anatomy, 419 
causes, 424 

premonitory stage, 426 
case, 430 

diagnosis, prognosis, 431, 432 
treatment, 434 
Microcephalus, 380 
Milk, human, 36 

its composition, 36-61 

its modification from diet, 37 

its modification from insufficient 

food, 38 
its modification from retention in 
the breast, 38 



INDEX. 



833 



Milk- 
its modification by age and mental 
impression, 39 

its modification by the catamenial 
function and pregnancy, 39 

differences in quantity and quality 
of milk, 41 

loss of milk (galactorrhea), 42 

scantiness, 42 

modes of increasing the milk, 43 

lactation, 43 

the electrical current, 45 

diet, 46 

use of the castor-oil plant, 46 

treatment of galactorrhoea, 47 

quantity required, 56, 57 

use of cow's and goat's, 62 

cow's, how prepared, 63 

condensed, 68 
Minot, Dr. Francis, on umbilical haemor- 
rhage, 86 
Morbilli, 178 
Morbus caeruleus, 793 
Mortality of early life, 24 

its causes, 25 

internal malformations, 25 

feebleness of system, 25 

hereditary disease, 25 

infectious diseases, 25 

anti -hygienic conditions, 25 

sudden change of temperature, 25 

diet, 25 
Mother, care of, in pregnancy, 19 

diet, 19 

exercise, 20 

diseases, 20 

mental excitement, 20 

its effect on the foetus, 20 

effect of injury on foetus, 23 
Mouth, gangrene of, 643 
Muguet,638 
Mumps, 310 

XTECROSIS infantilis, 643 

li Nervous cough, 630 

Nervous system, its condition as a means 
of diagnosis, 100 

Noma, 643 

Noyes, Prof. H. D. , on the use of the oph- 
thalmoscope, 375 

0'DWYER, Dr., on solvents of pseudo- 
membranes, 549 
(Esophagitis, 667 

anatomical characters, 668 
treatment, 669 
Oidium albicans, 639 
Ophthalmia neonati, 77 
causes, 77 
catarrhal form, 79 
treatment, 79 
blennorrhoeal form, 78 
symptoms, 78 
treatment, 79-82 
Ophthalmia, strumous, 138 



Ophthalmia — 

herpetic or phlyctenular keratitis, 
138 
its duration, diagnosis, progno- 
sis, 139 
treatment, 140 
parenchymatous or diffuse keratitis, 
141 
treatment, 142 
Oxyuris vermicularis, 747 

PARALYSIS, infantile, 498 
case, 499, 500 

symptoms, 501 

muscles affected, 502 

prognosis, progress, etiology, 503 

anatomical characters, 507 

diagnosis, prognosis, treatment, 508 
Paralysis, facial, causes, symptoms, 510 

prognosis, treatment, 511 
Paralysis, with pseudo-hypertrophy, 511 

anatomical characters, 513 

causes, 514 

prognosis, treatment, 515 
Paralysis, reflex, 516 
Parker, Dr. Kate, on the weight and 

growth of infants, 29 

on quantity of food required, 56 
Parker, Prof. Willard, case of peripha- 
ryngeal abscess, 666 
Parotiditis, 310 
Parotitis, 310 

nature, diagnosis, treatment, 311 
Peaslee, Prof. Edmund R., on treatment 

of croup, 551 
Peri-pharyngeal abscess, 661 

its cause, 663 

diagnosis, treatment, 666, 667 
Pertussis, 295 

age, causes, 296 

pathological anatomy, 297 

symptoms, first period, second pe 
riod, 298 

third or declining period, 299 

complications, convulsions, 300 

bronchitis, pneumonitis, 301 

emphysema, pulmonary collapse, 
302 

diagnosis, 304 

prognosis, 305 

treatment, belladonna, 306 

quinia, the bromides, 307,308 

use of the atomizer, 308 

prophylaxis, 309 
Pharangitis, catarrhal, anatomical char- 
acters, 658 

causes, symptoms, prognosis, 659 

diagnosis, treatment, 660 
Phelps, Dr. A. M., instrument for per- 
forming thoracentesis, 520 
Phlebitis, 387 

Phthisis {see Tuberculosis), 143 
Pleuritis, its frequency, 588 

causes, 590 

anatomical characters, 595 



834 



INDEX. 



Pleuritis — 

plastic or adhesive, 596 

sero-fibrinous, purgative, 597 

hemorrhagic, 598 

symptoms, 603 

physical signs, palpation, percus- 
sion, auscultation, 606-610 

diagnosis, prognosis, 610, 611 

treatment, 614 

thoracentesis, 618 
Pneumonitis, catarrhal, croupal, inter- 
stitial, causes, 573 

anatomical characters, 576 

cheesy pneumonitis, 579 

symptoms, 580 

physical signs, 583 

diagnosis, 584 

prognosis, treatment, 585 
Pomeroy, O. D., M.D., on ophthalmia 

neonati,80 
Post, Prof. Alfred, case of peri-pharyn- 

geal abscess, 666 
Post-mortem digestion, 680 

gelatinous softening of stomach, 681 

case, 682 
Pseudo-hypertrophy paralysis, 511 
Pulse in health, 95 

in disease, 97 

EACHITIS, 103 
age, 103 

causes, 105 

anatomical characters, 108 

craniotabes, 111 

symptoms, 116 

complications, diagnosis, 118 

laryngismus stridulus, 118 

prognosis and treatment, 119 
Remittent fever, 318 

symptoms, diagnosis, treatment, 319 
Respiration in infancy, 92 

in health, 93 

in disease, 94 
Respiratory system, its diseases, 529 
Reynolds, Dr. J. B., case of diphtheritic 
paralysis, 267 

case of empyema, 598 
Rheumatism, acute, 359 

causes, 360 

symptoms, 361 

duration, prognosis, 362 

diagnosis, 363 

treatment, 364, 365 
Rickets (see Rachitis), 103 
Ripley, Dr. John H. , statistics of trache- 
otomy, 553, 554 
Roseola, symptoms, 814 

causes, prognosis, diagnosis, 815 

treatment, 816 
Rotheln, 216 

premonitory stage, symptoms, 218 

the skin, mucous membrane, 218, 
219 

respiratory system, digestive sys- 
tem, pulse, temperature, 220 



Rotheln — 

complications, prognosis, nature, 
incubative period, contagious- 
ness, 221 

Rubeola, 178. 

SATTERTHWAITE, microscopic ex- 
amination of a case of diphtheria, 
263 
Seguin, Prof. E C, effect of maternal 

emotions on the foetus, 22 
Sewell, Dr. J. G., cases of cerebro-spinal 

fever, 331-336 
Scabies, 825 

itch animalcule, diagnosis, 826 
treatment, 827, 828 
Scarlatina, 40 
Scarlet fever, 187 

regular form, symptoms, 188 
irregular form, 191 
malignant form, 192 
complications, 193 

eclampsia, diphtheria, 192, 193 
gangrene of mouth, entero- 
colitis, 194 
articular rheumatism, cardiac 

inflammation, 194, 195 
nephritis, dropsy, 196, 197 
otitis, 196 

anatomical characters, 200 
nature, 201 
incubative period, 202 
diagnosis, prognosis, 203, 204 
prophylaxis, 214 
treatment, 206 

of nephritis ; of otitis, 210- 
212 
Scrofula, 120 
causes, 120 

vaccination as a cause of, 122 
anatomical characters, 124 
dactylitis, 127 
symptoms, 127 

relation of, to tuberculosis, 131 
prognosis, 131 
treatment, 132 

treatment of scrofulous diseases of 
the joints, 137 
Scrofulous ophthalmia, 138 
Skin diseases, 811 
Sleep, 71 

Smith, Prof. Stephen, 86 
Spasm of the glottis, 473 
Spinal irritation, 516 
Spinal cord and its coverings, diseases 
of, 515 
and its membranes, congestion of, 
517 
anatomical characters, 517 
symptoms, treatment, 518 
Spina bifida, 519 

diagnosis, prognosis, treatment, 521 
Splenization, 572 
Sprue, 638 
Starch, its digestion by infants, 64 



INDEX, 



835 



Stomach, congestion of, 674 

inflammation of, 675 
Stomach, post-mortem, softening, 680 
Stomatitis, simple ulcerous follicular, 
632 

simple or catarrhal, causes, 632 

symptoms, appearances, treatment, 
633 

ulcerous, causes, 634 

symptoms, prognosis, treatment, 
635 

aphthous, 636 

causes, symptoms, diagnosis, prog- 
nosis, treatment, 637 
Strophulus, 817 

varieties, 818 

treatment, 819 
Struma (see Scrofula), 120 

disease of joints, 137 
Strumous ophthalmia, 138 
St. Guy's dance, 481 
St. Vitus' dance, 481 
Syphilis, 167 

etiology, 167 

clinical history, 168 

coryza ; mucous patches, 170 

roseola, pemphigus, acne, impetigo, 
ecthyma, 171 

visceral lesions, 172 

osseous lesions, 173 

dactylitis syphilitica, 174 

dwarfing of incisor teeth ; intersti- 
tial keratitis, 175 

prognosis, treatment, 175 

TAYLOR, Dr. R. W., on dactylitis 
syphilitica, 173 
Taenia solium, 748 
Taenia saginat a, 750 
Taenia elliptica, 750 
Temperature in health and disease, 97 
Teething, 650 
Tetanus infantum, 453 
cases, 454, 455 

period of commencement, 455 
frequency in certain localitie3, 456 
causes, 457 
symptoms, 466 
mode of death, prognosis, duration 

of fatal cases, 469 
duration in favorable cases, diag- 
nosis, preventive treatment, 470 
treatment, 471 
Therapeutics of infancy and childhood, 

101 
Thoracentesis, indications for it, 618, 
619 
instruments to be used, and mode 
of operating, 620 
for sero-fibrinous exudations, 

621 
for empyema, 623 
admission of air into pleural cavity, 

624 
puncturing the lungs, 625 



Thoracentesis — 

washing out the pleural cavity, 626 
use of tent and drainage-tube, 628 
exsection of a portion of one or 
more ribs, 629 
Thrombosis in the cranial sinuses, 387 
anatomical characters, 387, 388 
causes, 389 
symptoms, 390 

diagnosis, prognosis, treatment, 391 
Thrush, 638 

anatomical characters, 638 
symptoms, causes, 640 
diagnosis, prognosis, treatment, 641 
Triocephalus dispar, 752 
Trismus infantum, 453 
Tuberculosis, 143 
etiology, 143 

general anatomical characters, 145 
anatomical characters in infancy 
and childhood, 146 
Tubercles in lungs, 146 

cavities, emphysema, 150 
Tubercles in abdominal viscera, 153 
stomach and intestines, 153 
general symptoms of tubercles, 155 
symptoms in cerebral tuberculosis, 
156 
in tubercles of bronchial glands, 

158 
physical signs, 159 
in tubercles of lungs, 159 
physical signs, 161 
in tubercles of pleura, 162 
in tubercles of stomach and in- 
testines, 162 
prognosis, treatment, 165 
Tubercular bronchial glanas, 151 
Typhoid fever, causes, anatomical char- 
acters, 320 

symptoms, 322 

complications, enteritis, intestinal 
haemorrhage, peritonitis, otitis, 
parotiditis, muguet, 324 
diagnosis, 325 
duration, prognosis, treatment, 326 

UMBILICUS, diseases of, 83 
inflammation of umbilical vein and 

arteries, 83 
inflammation and ulceration, 84 
umbilical granulations, 85 
haemorrhage of, 85 

sex, age, causes, 86 
symptoms, prognosis, treat- 
ment, 88 
Urticaria, causes, prognosis, diagnosis, 
treatment, 818 

VACCINIA, 236 

appearances, symptoms, 239 
anomalies, complications, sequels, 

240 
erysipelas, syphilis, 241 
subsequent vaccinations, 242 



836 



INDEX. 



Vaccinia — 

protection from vaccination, 243 

selection of virus, 245 
Vaccination a cause of scrofula, 122 
Varicella, symptoms, 246 

diagnosis, prognosis, 247 
Variola, 225 

incubative period, 225 

stage of invasion, stage of eruption, 
226 

stage of desiccation, 228 

varioloid, 229 

mode of death, 230 

anatomical characters, complica- 
tions, 231 

prognosis, diagnosis, 232 

treatment, 233 

local treatment, 234 
Vertebral caries, causes, 523 

symptoms, 525 

diagnosis, 526 

prognosis, treatment, 527 
Voss, Dr. , statistics of tracheotomy, 552 



WARREN, Dr., case of intussuscep- 
tion, 784 
Weaning, 52, 54 



Weight of infants, 29 
Wet-nursing, 29 
Wet-nurse, selection of, 48 

syphilis in, 48 

character of good milk, 49 

the lactometer, 49 

the lactoscope, 50 

use of microscope, 50 

micro-organisms in milk, 50 

return of the catamenia, 51 

weighing the infant, 51 
Whooping cough, 295 
Worms, intestinal, 744 

ascaris lumbricoides, 745 

oxyuris vermicularis, 747 

taenia solium, 748 

taenia saginata, or medio-canellata, 
750 

taenia elliptica, or cucumerina, 750 

bothriocephalus latus, 751 

trichocephalus dispar, 752 

causes, symptoms of the ascaris 
lumbricoides, 753 

symptoms from the oxyuris ver- 
micularis, 755 

symptoms from taenia, diagnosis, 
756 

prognosis, treatment, 757 



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It is issued quarterly, in January, April, July, and October, each number containing 
about three hundred octavo pages, appropriately illustrated wherever necessary. A 
large portion of this space is devoted to Original Communications, embracing papers 
trom the most eminent members of the profession throughout the country. 

Following this is the Review Department, containing extended reviews by com- 
petent writers of prominent new works and topics of the day, together with numerous 
elaborate Analytical and Bibliographical Notices, giving a fairly complete survey of 
medical literature. 

Then follows the Quarterly Summary of Improvements and Discoveries 
in the Medical Sciences, classified and arranged under different heads, and furn- 
ishing a digest of medical progress, abroad and at home. 

Thus during the year 1880 the "Journal" contained 67 Original Communications, 
mostly elaborate in character, 170 Reviews and Bibliographical Notices, and 147 articles 
in the Quarterly Summaries, illustrated with 47 wood engravings. 

That the efforts thus made to maintain the high reputation of the "Journal" are 

successful, is shown by the position accorded to it in both America and Europe as the 

leading organ of medical progress: — 

This is universally acknowledged as the leading i The Philadelphia Medical and Physical Journal 
American Journal, and has been conducted by Dr. I issued its first number in 1820, and, after a brilliant 
Hays alone until 1869, when his son was associated ! career, was succeeded in 1S27 by the American 
with him. We quite agree with the critic, that this j Jouvual .oi the Medical Sciences, a periodical of 
journal issecond to none in the language, and cheer- j world-wide* reputation ; the ablest and one of the 
fully accord to it the first place, for nowhere shall oldest periodicalsin the world — a journal which has 
we find more able and more impartial criticism, and : an unsulli'ed record. — Gross's History of American 



nowhere such a repertory of able original articles 
Indeed, now that the "British and Foreign Medico- 
Chirurgical Review" has terminated its career, the 
American Journal stands without a rival. — London 
Med. Times and Gazette, Nov. 24, 1877. 

The best medical journal on the continent. — Bos- 
ton Med. and Surg. Journal, April, 1879. 

The present number of the American Journal is 
an exceedingly good one, and gives every promise 
of maintaining the well-earned reputation of the 
review. Our venerable contemporary has our best 
wishes, and we can only express the hope that it 
may continue its work with as much vigor and ex- 
cellence for the next fifty years as it has exhibited 



Med. Literature 1876. 

The besfrmedicah j ournal ever published in Europe 
or America. — Va. Med. Monthly, May, 1879. 

It is universally acknowledged to be the leading 
American medical journal, and, in our opinion, is 
second to none in the language. — Boston Med. and 
Surg. Journal, Oct. 1877. 

This is the medical journal of our country to which 
the American physician abroad will point with the 
greatest satisfaction, as reflecting the state of medi- 
cal culture in his country. For a great many years 
it has been the medium through which our ablest 
writers have made known their discoveries and 
observations. — Aadress of L. P. Tan dell, M.D., he- 



rn the past.— .London Lancet, Nov. 24, 1877. \ fore Inte rnational Med. Congress, Sept. 1876. 

And that it was specifically included in the award of a medal of merit to the Pub- 
lishers in the Vienna Exhibition in 1873. 

The subscription price of the "American Journal of the Medical Sciences" 
has never been raised during its long career. It is still Five Dollars per annum ; 
and when paid for in advance, the subscriber receives in addition the "Medical 
News and Abstract," making in all nearly 2000 large octavo pages per annum, free 
of postage. 

THE MEDICAL NEWS AND ABSTRACT. 

Thirty-eight years ago the "Medical News" was commenced as a monthly to 
convey to the subscribers of the "American Journal" the clinical instruction and 

* Communications are invited from gentlemen in all parts ©f the country % Articles inserted by the 
Editor are liberally paid for by the publishers. 



Henry C. Lea's Son & Co.'s Publications — (Am. Journ. Med. Sci.). 3 

current information which could not be accommodated in the Quarterly. It consisted 
of sixteen pages of such matter, together with sixteen more known as the Library 
Department and devoted to the publishing of books. With the increased progress of 
science, however, this was found insufficient, and some years since another periodical, 
known as the "Monthly Abstract," was started, and was furnished at a moderate 
price to subscribers to the "American Journal." These two monthlies have been 
consolidated, under the title of "The Medical News and Abstract," and are 
furnished free of charge in connection with the "American Journal." 

The "News and Abstract" consists of 64 pages monthly, in a neat cover. It 
contains a Clinical Department in which will be continued the series of Original 
American Clinical Lectures, by gentlemen of the highest reputation through- 
out the United States, together with a choice selection of foreign Lectures and 
Hospital Notes and Gleanings. Then follows the Monthly Abstract, systemati- 
cally arranged and classified, and presenting five or six hundred articles yearly ; and 
each number concludes with an Editorial and a News Department, giving cur- 
rent professional intelligence, domestic and foreign, the whole fully indexed at the close 
of each volume, rendering it of permanent value for reference. 

As stated above, the subscription price to the "News and Abstract" is Two 
Dollars and a Half per annum, invariably in advance, at which rate it ranks as one 
of the cheapest medical periodicals in the country. But it is also furnished, free of 
all charge, in commutation with the "American Journal of the Medical 
Sciences," to all who remit Five Dollars in advance, thus giving to the subscriber, 
for that very moderate sum, a complete record of medical progress throughout the 
world, in the compass of about two thousand large octavo pages. 

In this effort to furnish so large an amount of practical information at a price so un- 
precedentedly low, and thus place it within the reach of every member of the profes- 
sion, the publishers confidently anticipate the friendly aid of all who feel an interest in 
the dissemination of sound medical literature. They trust, especially, that the sub- 
scribers to the "American Medical Journal," will call the attention of their 
acquaintances to the advantages thus offered, and that they will be sustained in the 
endeavor to permanently establish medical periodical literature on a footing of cheap- 
ness never heretofore attempted. 

PREMIUM TOR OBTAINING NEW SUBSCRIBERS TO THE •■ JOURNAL." 

Any gentleman who will remit the amount for two subscriptions for 1881, one of 
which at least must be for a new subscriber, will receive as a premium, free by mail, 
a copy of any one of the following recent works : — 
"Seiler on the Throat" (see p. 19), 
"Barnes's Manual of Midwifery" (see p. 24), 
"Browne on the Use of the Ophthalmoscope" (see p. 29), 
"Flint's Essays on Conservative Medicine" (see p, 15), 
"Sturges's Clinical Medicine" (see p. 15), 
"Tanner's Clinical Manual" (see p. 5), 
"West on Nervous Disorders of Children" (see p. 21). 

\* Gentlemen desiring to avail themselves of the advantages thus offered will do 
well to forward their subscriptions at an early day, in order to insure the receipt of 
complete sets for the year 1881. 

IjjgfT The safest mode of remittance is by bank check or postal money order, drawn 
to the order of the undersigned. Where these are not accessible, remittances for the 
"Journal" maybe made at the risk of the publishers, by forwarding in registered 
letters. Address, 

Henry C. Lea's Son & Co., Nos. 706 and 708 Sansom. St., Phila., Pa. 



Henry C. Lea's Son & Co.'s Publications — (Dictionaries). 



JJUNGLISON {ROBLEY), M.D., 

"^"^ Late Professor of Institutes of Medieinein Jefferson Medical College, Philadelphia 

MEDICAL LEXICON; A Dictionary op Medical Science: Con- 
taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, 
Pathology, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery. Obstetrics, Medical 
Jurisprudence and Dentistry. Notices of Climate and of Mineral Waters; Formulae for 
Officinal, Empirical and Dietetic Preparations; with the Accentuation and Etymology of 
the Terms, and the French and other Synonymes ; so as to constitute a French as well as 
English Medical Lexicon. A New Edition. Thoroughly Revised, and very greatly Mod- 
ified aad Augmented. By Richard J. Dunglison, M.D. In one very large and hand- 
someroyal octavo volume of over 1100 pages. Cloth, $6 50 ; leather, raised bands, $7 50 ; 
half Russia, #8. (Lately Issued.) 
The object of the author from the outset has not been to make the work a mere lexicon or 
dictionary of terms, but to afford, under each, a condensedviewof its various medical relations, 
and thus to render the work an epitome of the existing condition of medical science. Starting 
with this view, the immense demand which has existed for the work has enabled him, in repeated 
revisions, to augmentits completeness and usefulness, until at lengthit has attained the position 
of a recognized and standard authority wherever the language is spoken. 

Special pains have been taken in the preparation of the present edition to maintain this en- 
viable reputation During the ten years which have elapsed since the last revision, the additions 
to the nomenclature of the medical sciences have been greater than perhaps iD any similar period 
of the past, and up to the time of his death the author labored assiduously to incorporate every- 
thing requiring the attention of the student or practitioner. Since then, the editor has been 
equally industrious, so that the additions to the vocabulary aremore numerous than in any pre- 
vious revision. Especial attention has been bestowed on the accentuation, which will be found 
marked on every word. The typographical arrangement has been much improved, rendering 
reference much more easy, and every care has been taken with the mechanical execution. The 
work has been printed on new type, small but exceedingly clear, with an enlarged page, so that 
the additions have been incorporated with an increase of but little over a hundred pages, and 
the volume now contains the matter of at least four ordinary octavos. 
A book well Known to our readers, and of which 



everv American ought to be proud. When the learned 
author of the work passed away, probably all of as 
feared lest the book should not maintain its place 
in the advancing science whose terms it defines. For- 
tunately, Dr. Richard J. Dunglison. having assisted his 
father in the revision of several editions of the work, 
aDd having been, therefore, trained in themethods and 
imbued with the spirit of the book, has been able to 
edit it. not in the patchwork manner so dear to the 
heart of book editors, so repulsive to the taste of intel- 
ligent book readers, but to edit it as a work of the kind 
should be edited— to carry it on steadily, without jar 
or interruption, along the grooves of thought it has 
travelled during its lifetime. To show the magnitude 
of the task which Dr. Dunglison has assumed and car- 
ried through, it is only necessary to state that more 
than six thousand new subjects have been added in the 
present edition. — Phila. Med. Times, Jan. 3, 1874. 

About the hrst book purchased by the medical stu- 
dent is the Medical Dictionary. The lexicon explana- 
tory of technical terms is simply a sine qua non . In a 
scie"nce so extensive, and with such collaterals as medi- 
cine, it is as much a necessity also to the practising 
physician. To meet the wants of students and most 
physicians, the dictionary must be condensed while 
comprehensive, and practical while perspicacious. It 
was because Dunglison's met these indications that it 
became at once the dictionary of general use wherever 
medicine was studied in the English language. In no 
former revision have thealterations and additions been 
so great. More than six thousand new subjects and terms 
have been added. The chief terms have been set in black 
letter, while Lhe derivatives follow in small caps; an 
arrangement which greatly facilitates reference. We 



may safely confirm the hope ventured by the editor 
"that the work, which possesses for him a filial as well 
a.s an individual interest, will be fouDd worthy a con- 
tinuance of the position so long accorded to it as a 
standard authority." — Cincinnati Clinic. Jan. 10. 1874. 
It has the rare merit that it certainly has v.<- rival 
in the English language for accuracy and ex'eni of 
references. — London Medical (Gazette . 

As a standard work of reference, as one of the best, 
if not the very best, medical dictionary in the Eng- 
lish language, Dunglison's work has been well known 
for about forty years, and needs no words of praise 
on our part to recommend it to the members of the 
medical, and, likewise, of the pharmaceutical pro- 
fession. The. latter especially are in need of such a 
work, which gives ready and reliable information 
on thousands of subjects and terms which they are 
liable to encounter in pursuing their daily avoca- 
tions, but with which they cannot be expected to be 
familiar. The work before us fully supplies this 
want. — Am. Journ. of Pharm., Feb. 1S74. 

A valuable dictionary of the terms employed in 
medicine and the allied sciences, and of the rela- 
tions of the subjects treated under each head. It re- 
flects great credit on its able American author, and 
well deserves the authority and popularity it has 
obtained.— British Med. Journ., Oct. 31, 1S74. 

Few works of this class exhibit a grauder monu- 
ment of patient research and of scientific lore. The 
extent of the sale of this lexicon is suflicient to tes- 
tify to its u>e : ulness, and to the great service con- 
ferred by Dr. Eobley Dunglison on the profession, 
and indeed on others, by its issue. — London Lancet , 
May 13 1.-75. 



UOBLYN [RICHARD D.), M.D 

A DICTIONARY OF THE TERMS USED IN MEDICINE AND 

THE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac Hays, 
M. D., Editor of the " American Journal of the Medical Sciences." In one large royal 
12mo. volume of over 500 double-columned pages : cloth, $1 50 : leather, $2 00 
It is the best book of definitions we have, and ought always to be upon the student's table.— Southern 
Med. and Surg. Journal. 

T>OD WELL [G. F.), F.R.A.S., frc. 

A DICTIONARY OF SCIENCE: Comprising Astronomy, Chem- 
istry, Dynamics, Electricity. Heat, Hydrodynamics, Hydrostatics, Light, Magnetism, 
Mechanics, Meteorology, Pneumatics, bound and Statics. Preceded by an Essay on the 
History of the Physical Sciences. In one handsome octavo volume of 694 pages, with 
many illustrations : cloth, $5. 



Henry C. Lea's Sox & Co.'s Publications — (Manuals'), 5 

A CENTURY OF AMERICAN MEDICINE, 1776-1876. By Doctors E. H. 
-"• Clarke, H. J. Bigelow, S. D. Gross, T. G. Thomas and J. S. Billings. In one very hand- 
some 12mo. volume of about 350 pages : cloth, $2 25. 

This work appeared in the pages of the American Journal of the Medical Sciences during the 
year 1876. As a detailed account of the development of medical science in America, by gentle- 
men of the highest authority in their respective departments, the profession will no doubt wel- 
come it in a form adapted for preservation and reference. 



JSTEILL {JOHN), M.D., and &MITH {FRANCIS O.), M.D., 

Prof, of tke Institutes of Medicine inthe Univ. of Penna. 

AN ANALYTICAL COMPENDIUM OF THE VARIOUS 

BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. A 
new edition, revised and improved. In one very large and handsomely printed royal 12mo. 
volume, of about one thousand pages, with 374 wood-cuts, cloth, $4 ; strongly bound in 
leather, with raised bands, $4 75. 



H 



ARTSHORNE {HENRY), 31. D., 

Professor of Hygiene in the University of Pennsylvania. 

A CONSPECTUS OF THE MEDICAL SCIENCES; containing 

Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine*, 
Surgery and Obstetrics. Second Edition, thoroughly revised and improved. In one lar°- e 
royal 12mo. volume of more than 1000 closely printed pages, with 477 illustrations on 
wood. Cloth, $4 25 ; leather, $5 00. 
We can say with the strictest truth that it is the | worthy. If students must have a conspectus, they 
best work of the kind with which w<. art acquainted, will be wise to procure that of Dr. Hartshorne — 
It embodiesinacondensed form all recent contribu- Detroit Rev. of Med. and Pharm. Aug 1S74 
tions to practical medicine ana is therefore useful Th k b f h redeeming features 

to every busy practitioner throughout our country, QQt osse8aed b oth £d is the be" t we have 

besides being admirably adapted to the use of stu- * „ Bart / horne exhibits much skill fn con- 

dents of medicine. The book is faUhtully and ably donsation . It is well ad ted to lhe p ^ 8ic ? a J ? n 
QXBCutei.-Charleston Med. Journ., April, 1875. ; active practice , who ca .n give butlimited time to tie 
The work is intended as an aid to the medical familiarizing of himself with the important changes 
student, and as such appears to admirably fulfil its which have been made since he attended lectures, 
object by its excellent arrangement, the full compi- The manual of physiology has also been improved 
lation of fact6, the perspicuity and terseness of Ian- and gives the most comprehensive view of the latest 
'guage, and the clear and instructive illustrations advances in the science possible in the space devoted 
in some parts of the work.— American Journ. of to the subject. The mechanical exscution of the 
Pharmacy, Philadelphia, July, 1S7-4. | book leaves nothing to be wished for.— Peninsular 

The volume will be found useful, not only to stu- ' Journal of Medicine, Sept. 1874. 
dents, bnt to many others whomay desire torefresh ; After carefully looking through this conspectus, 
their memories with the smallest possible expendi- we are constrained to say that it is the most com- 
tnre of time.— N. Y. Med. Journal, Sept. 1S74. plete work, especially in its illustrations, of its kind 

The student will find this the most convenient and that we have seen.— (Xneinnati Lancet, Sept. 1S74. 
useful book of the kind on which he can lay his The favor with wM h h fi 
hand.-PacySe Med. and Surg. Journ., Aug. ltf 4. CompeQdinm was rece ived, was an evidence of its 
This is the best book of its kind that we have ever various excellences. The present edition bears evi- 
examiued. It is an honest, accurate, and concise dence of a careful and thorough revision. Dr. Harts- 
compend of medical sciences, as fairly as possible borne possesses a happy faculty of seizing upon the 
representing their present condition. The chances salient points of each subject, and of presenting them 

and the additions have been so judicious and tho- \ in a concise and yet perspicuous manner. Leaven- 

rough as to render it.so far as it goes, entirely trust- 1 worth Med. Herald, Oct. 1S74. 



TUDLOW {J.L.), M.D. 
A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, 

Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy and 
Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised 
and greatly extended and enlarged. With 370 illustrations In one handsome royal 
12mo. volume of 816 large pages. Cloth, S3 25 ; leather, $3 75. 
The arrangement of this volume in the form of question and answer renders it especially suit- 
able for the office examination of students, and for those preparing for graduation. 



WANNER {THOMAS HAWKES), M.D., £c. 

1 A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- 

NOSIS. Third American from the Second London Edition. Revised and Enlarged by 
Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital, 
London, &c. In one neat volume, small 12mo., of about 375 pages, cloth, $150. 
*%* On page 3, it will be seen that this work is offered as a premium for procuring new 
subscribers to the "American Journal op the Medical Sciences.' 1 



G 



Henry C. Lea's Son & Co.'s Publications — {Anatomy), 
JRAY {HENRY), F.R.S., 

Lecturer on Anatomy at St. George'' 8 Hospital, London. 



ANATOMY, DESCRIPTIVE AND SURGICAL. The DrawiDgs by 

H. V. Carter, M.D., and Dr. Westmacott. The Dissections jointly by the AuTHORand 
Dr. Carter. With an Introduction on General Anatomy and Development by T. 
Holmes, M.A., Surgeon to St. George's Hospital. A new American, from the Eighth 
enlarged and improved London edition. To whichis added " Landmarks, Medical and 
Surgical," by Luther Holden, E.R.C.S., author of "Human Osteology," " A Manual 
of Dissections," etc. In one magnificent imperial octavo volume of 983 pages, with 
522 large and elaborate engravings on wood. Cloth, $6; leather, raised bands, $7; 
half Russia, $7 50. 
The author has endeavored in this work to cover a more extendedrange of subjects than is cus- 
tomary in the ordinary text-books, by giving not only the details necessary for the student, but 
also the application of those details in the practice of medicine and surgery, thus rendering it both 
a guide for the learner, and an admirable work of reference for the active practitioner. The en- 
gravings form a special feature in the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in place of 
figures of reference, with descriptions at the foot. They thus form a complete and splendid series, 
which will greatly assist the studentin obtaining a clear idea of Anatomy, and will also serve to 
refresh the memory of those who may find in the exigencies of practice the necessity of recalling 
the details of the dissecting room ; while combining, as it does, a complete Atlas of Anatomy, witb 
a thorough treatise on systematic, descriptive and applied Anatomy, the work will be found of 
essential use to all physicians who receive students in their offices, relieving both preceptor and 
pupil of much labor in laying the groundwork of a thorough medical education. 

Since the appearance of the last American Edition, the work has received three revisions at the 
hands of its accomplished editor, Mr. Holmes, who has sedulously introduced whatever has seemed 
requisite to maintain its reputation as a complete and authoritative standard text-book and work 
of reference. Still further to increase its usefulness, there has been appended to it the recent 
work by the distinguished anatomist, Mr. Luther Holden — "Landmarks, Medical and Surgical" 
—which gives in a clear, condensed and systematic way, all the information by which the prac- 
titioner can determine from the external surface of the body the position of internal parts. Thus 
complete, the work, it is believed, will furnish all the assistance that can be rendered by type and 
illustration in anatomical study. No pains have been spared in the typographical execution of 
the volume, which will be found in all respects superior to former issues. Notwithstanding the 
increase of size, amounting to over 100 pages and 57 illustrations, it will be kept, as heretofore, 
at a price rendering it one of the cheapest works ever offered to the American profession. 



The recent work of Mr. Holden, which was no- 
ticed by us on p. 53 of this volume, has been added 
as an appendix, so that, altogether, this is the most 
practical and complete anatomical treatise available 
to American students and physicians. The former 
finds in it the necessary guide in making dissec- 
tions ; a very comprehensive chapter on minute 
anatomy ; and about all that can be taught him on 
general and special anatomy; while the latter, in 
its treatment of each region from a. surgical point of 
view, and in the valuable addition of Mr. Holden, 
will 'find all that will be essential to him in his 
practice.— New Remedies, Aug. 187S. 

This work is as near perfection as one could pos- 
sibly or reasonably expect any book intended as a 
text-book or a generaJ reference book on anatomy 
to be. The American publisher deserves the thanks 
of the profession for appending the recent work of 
Mr. Holden, "Landmarks, Medical and Surgical,'" 
which has already been commended as a separate 
book. The latter work— treating of topographical 
anatomy — has become an essential to the library of 
every intelligent practitioner. We know of no 
book that can take its place, written as it is by a 
most distinguished anatomist. It would be simply 
a waste of words to say anything further in praise 
of Gray's Anatomy, the text-book in almost every 
medical college in this country, and the daily refer- 
ence book of every practitioner who has occasion 



to consult his books on anatomy. The work is 
simply indispensable, especially this present Amer- 
ican edition.— Fa. Med. Monthly, Sept. 1878. 

The addition of the recent work of Mr. Holden, 
as an appendix, renders this the most practical and 
complete treatise available to American students, 
who find in it a comprehensive chapter on minute 
anatomy, about all that can be taught on general 
and special anatomy, while its treatment of each 
region, from a surgical point of view, in the valu- 
able section by Mr. Holden, is all that will be essen- 
tial to them in practice.— Ohio Medical Recorder, 
Aug. 1878. 

It is difficult to speak in moderate terms of this 
new edition of "Gray." It seems to be as nearly 
perfect as it is possible to make a book devoted to 
any branch of medical science. The labors of the 
eminent men who have successively revised the 
eight editions through which it has passed, would 
seem to leave nothing for future editors to do. The 
addition of Holden's " Landmarks" will make it as 
indispensable to the practitioner of medicine and 
surgery as it has been heretofore to the student. As 
regards completeness, ease of reference, utility, 
beauty, and cheapness, it has no rival. No stu- 
dent should enter a medical school without it ; no 
physician can afford to have it absent from his 
library.— Si. Louis Clin. Record, Sept. 1878. 



Also for sale separate — 
TTOLDEN [LUTHER), F.R.C.S., 

JLJL Surgeon to St. Bartholomew's and the Foundling Hospitals. 

LANDMARKS, MEDICAL AND SURGICAL. Second American, 

from the Latest Revised English Edition, with additions by W. W. Keen, M.D., Prof, of 
Artistic Anatomy in the Penna. Academy of the Eine Arts, formerly Lecturer on Anat- 
omy in the Phila. School of Anatomy. In one handsome 12mo. volume, of about 140 
pages. Cloth, $1.00. (Just Ready.) 

EATH {CHRISTOPHER), F.R.G.S., 

Teacher of Operative Surgery in University College, London. . 

PRACTICAL ANATOMY: A Manual of Dissections. From the 

Second revised and improved London edition. Edited, with additions, by W. W. Keen, 
M. D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia. 
In one handsome royal 12mo. volume of 578 pages, with 247illustrations. Cloth, $3 50 ; 
leather, $4 00. 



H 



Henry C. Lea's Son & Co.'s Publications — (Anatomy). 7 

A LLEN (HARRISON), M.D. 

•*■*- Professor of Physiology in the Univ. of Pa. 

A SYSTEM OF HUMAN ANATOMY: INCLUDING ITS MEDICAL 

and Surgical Relations. For the Use of Practitioners and Students of Medicine. With an 
Introductory Chapter on Histology. By E. 0. Shakespeare, M D., Ophthalmologistto the 
Phila. Hosp. In one large and handsome quarto volume, with several hundred original 
illustrations on lithographic plates, and numerous wood-cuts in the text. (Shortly.) 
In this elaborate work, which has been inactive preparation for several years, the author has 
Bought to give, not only the details of descriptive anatomy in a clear and condensed form, but also 
the practical applications of the science to medicine and surgery. The workthus has claims upon 
the attention of the general practitioner, as well as of the student, enabling him not only to re- 
fresh his recollections of the dissecting room, but also to recognize thesignificance of all varia- 
tions from normal conditions. The marked utility of the object thus sought by.the author is 
self-evident, and his long experience and assiduous devotion to its thorough development are a 
sufficient guarantee of the manner in which his aims have been carried out. No pains have been 
spared with the illustrations. Those of normal anatomy are from original dissections, drawn on 
stone by Mr. Herui#nn Faber, with the name of every part clearly engraved upon the figure 
after the manner of " Holden" and "Gray." and in every typographical detail it will be the 
effort of the publishers to render the volume worthy of the very distinguished position which is 
anticipated for it. 

ffLLIS {GEORGE V1NER)~ 

-U Emeritus Professor of Anatomy in University College, London. 

DEMONSTRATIONS OF ANATOMY; Being a Guide to the Know- 

ledge of the Human Body by Dissection. By George Viner Ellis, Emeritus Professor 
of Anatomy in University College, London. From the Eighth and Revised London 
Edition. In one very handsome octavo volume of over 700 pages, with 256 illustrations. 
Cloth, $4.25 ; leather, $5.25. (Lately Issued.) 
This work has long been known in England as the leading authority on practical anatomy, 
and the favorite guide in the dissecting-room, as is attested by the numerous editions through 
which it has passed. In the last revision, which has just appeared in London, the accomplished 
author has sought to bring it on a level with the most recent advances of science by making the 
necessary changes in his account of the microscopic structure of the different organs, as devel- 
oped by the latest researches in textural anatomy. 

Ellis's Demonstrations is the favorite text-book its leadership over the English manuals upon dis- 
of the English student of anatomy. In passing secting.— Phila. Med. Times, May 24, 1S79. 
through eight editions it has been so revised and 

adapted to the needs of the student that it would As . a dissector, or a work to have in hand and 
seem that it had almost reached perfection in this studied while one is engaged in dissecting, we re- 
special line. The descriptions are clear, and the § ard u as the very best work extant, which is cer- 
methods of pursuing anatomical investigations are tainly saying a very great deal. As a text-book to 
given with such detail that the book is honestly be studied in the dissecting-room, it is superior to 
entitled to its name.— St. Louis Clinical Record, j an 7 of the works upon anatomy.— Cincinnati Med. 
June, 1879. flew*, May 24, 1879. 

The success of this old manual seems to be as well We most unreservedly recommend it to every 
deserved in the present as in the past volumes, practitioner of medicine who can possibly get it — ■ 
The book seems destined to maintain yet for years I Va. Med. Monthly, June, 1879. 

ILSON {ERASMUS), F.R.S. 

A SYSTEM OF HUMAN ANATOMY, General and Special. Edited 

byW. H.Gobrecht, M.D., Professor of General and Surgical Anatomy in the Medical Col- 
lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In 
one large and handsome octavo volume, of over 600 pages ; cloth, $4 ; leather, $5. 

MITH {HENRY H.), M.D., and JJORNER ( WILLIAM E.),M.D., 

Prof, of Surgery in the Univ. ofPenna., &c. Late Prof, of Anatomy in the Univ. ofPenna. 

AN ANATOMICAL ATLAS ; Illustrative of the Structure of the 

Human Body. In one volume, large imperial octavo, cloth, with about six hundred and 
fifty beautiful figures. $4 50. 

VCRAFER {EDWARD ALBERT), AID., 

*-2 Assista?it Professor of Physiology in University College, London. 

A COURSE OF PRACTICAL HISTOLOGY: Being an Introduction to 

the Use of the Microscope. In one handsome royal 12mo. volume of 304 pages with 
numerous illustrations: cloth, $2 00. (Lately Issued.) 

HORNER'S SPECIAL ANATOMY AND HISTOL- for their Pass Examination. With engravings on 
OGT. Eighth edition, extensively revised and \ wood. In one handsome royal 12mo volume 
modified. In 2 vols. Svo., of over 1000 pages, Cloth, $225. " vuluine - 

with 320 wood-cuts : cloth, $6 00. I CLE LAND'S DIRECTORY FOR THE DISSECTION 

SHARPEY AND QUAIN'S HUMAN ANATOMY. OF TBE HUMAN BODY. In one Jail volam? 
Revised, by Joseph Leidy, M.D., Prof of Anat. royal 12mo. of 182 pages- cloth *1 2a 

fts&v. sshiissas: vo ciot°h f , as ^s^ssss? ^sx^v* anato , my t and 

BELLAMY'S STUDENT'S GUIDE TO SURGICAL fo" 8 ™™ 6 ^ ^ 

ANATOMY: A Text-book for Students preparing $175. ' Cl0th 



w 



s 



s 



Henry C. Lea's Son & Co.'s Publications — {Physiology). 



/)ALTON (J. C), M.D., 

•*~S Professor of Physiology in the Oollegeof Physicians and Surgeons, New York,&c. 

A TREATISE ON HUMAN PHYSIOLOGY. Designed for the use 

of Students and Practitioners of Medicine. Seventh edit., thoroughly revised and rewrit- 
ten, with about three hundred and sixty illustrations on wood. In one very beautilul 
octavo volume, of about 900 pages. (Nearly Ready.) 



A few notices of the previous edition are appe 
Prof. Dalton has discu^ed conflicting theories and 
conclusions regarding physiological questions with a 
fairness, a fulness, and a conciseness which lend fresh- 
ness and vigor to the entire book. But his discussions 
have been so guarded by a refusal of admission to those 
speculative and theoretical explanations, which at best 
exist in the minds of observers themselves as only pro- 
babilities, that none of his readers need be led into 
grave errors while making them a study. — The Medical 
Record, Feb. 19, 1876. 

For clearness and perspicuity, Dalton's Physiology 
commended itself to the student years ago, and was a 
pleasant relief from the verbose productions which it 
supplanted. Physiology has, however, made many ad- 
vances since then— and while the style has been pre- 
served intact, the work in the present edition has been 
brought upf ully abreastof the times. Thenew chemical 
notation and nomenclature have also been introduced 
into the present edition. Notwithstanding the multi- 



nded. 

pin-ity of text-books on physiology, this will lose none 
of its old time popularity. The mechanical execution 
of the work is all that could be desired. — Peninsular 
Journal of Medicine, Dec. 1875. 

This popular text-book on physiology comes to us in 
its sixth edition with the addition of about fifty percent, 
of now matter, chiefly in the departments of patho- 
logical chemistry and the nervous system, where the 
principal advances have been realized. With so tho- 
rough revision and additions, ^hat keepthe work well 
up to the times, its continued popularity may be confi- 
dently predicted, notwithstanding the competition it 
may encounter. The publisher's work is admirably 
done. — St. Louis Med. and Surg.Journ., Dec. 1875. 

The revision of thisgreatwork has^roughtitforward 
with the physiological advances of the day, and renders 
it, as it has ever been, the fioest work for students ex- 
tant. — Nashville Jburn.of Med. and Surg., Jan. 187 6. 



flABPENTER ( WILLIAM B.), M. D., F. R. S., F.G.S., F.L.S., 

V^ Registrar to University of London, etc . 

PRINCIPLES OF HUMAN PHYSIOLOGY; Edited by HenryPower, 

M.B. Lond., F.R.C.S., Examiner in Natural Sciences, University of Oxford. Anew 
American from the Eighth Revised and Enlarged English Edition, with Notes and Addi- 
tions, by Francis G. Smith, M.D., Professor oi thelnstitutescf Medicinein the Univer- 
sity of Pennsylvania, etc. In one very large and handsome octavo volume, oi 1083 pages, 
with two plates and 373 engs. on wood. Cloth, $5 50; leather, $6 50 ; half Russia, $7. 



"We have been agreeably surprised to find the vol- 
ume so complete in regard to the structure and func- 
tions of the nervous system in all its relations, a 
subject that, in many respects, is one of the most diffi- 
cult of all, in the whole range of physiology, upon 
which to produce a full and satisfactory treatise of 
the class to which the one before us belongs. The 
additions by the American editor give to the work as 
it is a considerable value beyond that of the last 
English edition. In conclusion, we can give our cor- 
dial recommendation to the work as it now appears. 
The editors have, with their additions to the only 
work on physiology in our language that, in the full- 
est sense of the word, is the production of a philoso- 
pher as well as a physiologist, brought it up as fully 
as could be expected, if not desired, to the standard 
of our knowledge of its subject at the present day. 
It will deservedly maintain the place it has always 
nad iu the favor of the medical profession. — Journ. 
of Nervous and Mental Disease, April, 1877. 

Such enormous advances have recently been made in 
our physiological knowledge, that what was perfectly 



50 

new a year or two ago. looks now as if it had been a 
received and established fact for years. In this ency- 
clopaedic way it is unrivalled. Here, as it seems to 
us, is thegreatvaiue of the book; one is safe in sending 
a student to it for information on almost any given 
subject, perfectly certain of the fulness of information 
it will convey, and well satisfied of the accuracy with 
which it will there be found stated. — London Med. 
Times and Gazette, Feb. 17, 1877. 

The meritsof "Carpenter's Physiology" are so widely 
known and appreciated that we need only allude briefly 
to the fact that in the latest edition will be found a com- 
prehensive embodiment of the results of recent physio- 
logical investigation. Care has been taken to preserve 
the practical character of the original work. In fact 
the entire work has been brought up to date, and bears 
evidence of the amount of labor that has been bestowed 
upon it by its distinguished editor, Mr. Henry Power. 
The American editor has made the latest additions, in 
order fully to cover the time that has elapsed since the 
last English edition.— If. Y. Med. Journal, Jan. 1877 . 



IjTOSTER {MICHAEL), M.D., F.R.S., 

J. Prof, of Physiology in Cambridge Univ., England. 

TEXT-BOOK OF PHYSIOLOGY. Second American from the Latest 

English Edition. Edited, with Extensive Notes and Additions, by Edward T. Reichert, 
M.D., Late Demonstrator of Experimental Therapeutics in the Univ. of Penna. In one 
handsome royal 12mo. volume of about 1000 pages, with 260 illust. (Nearly Ready.) 
In the preparation of a second American edition of Mr. Foster's Physiology, the editor has 
endeavored to render it more than ever acceptable to the student as a clear and comprehensive 
text-book, presenting the science in its latest developments. The original work being an ex- 
position of functional, rather than general physiology, it seemed desirable to introduce the 
details of structure, in order to render more intelligible to the student the views and theories 
oi the science. These the editor has added, in as concise a manner as possible; and in aid of 
this end has freely introduced illustrations irom recognized authorities. 

LEHMANN'S MANUAL OF CHEMICAL PHYSIOL-| LEHMANN'S PHYSIOLOGICAL CHEMISTRY. Com- 
OGY. Translated from the German, with Notes j piete in two large octavo volumes of 1200 pages 
and Additions, by J. Chestok Mokris, M.D. With with 200 illustrations ; cloth, $6. 
illustrations on wood. In one octavo volume oi 
336 pages. Cloth, $2 25. | 



Henry C. Lea's Son & Co.'s Publications — (Chemistry). 



A TTFIELD (JOHN), Ph.D., 

-"- Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, &c . 

CHEMISTRY, GENERAL, MEDICAL AND PHARMACEUTICAL; 

Including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles 
of the Science, and their Application to Medicine and Pharmacy. Eighth edition, revised 
hy the author. In one handsome royal 12mo. volume of 700 pages, with illustrations. 
Cloth, $2 50 ; leather, $3 00. {Now Ready.) 



We have repeatedly expressed our favorable 
opinion of this work, and on the appearance of a 
new edition of it, little remains for us to say, ex- 
cept that we expect this eighth edition to he as 
indispensable to us as the seventh and previous 
editions have been. While the general plan and 
arrangement have been adhered to, new matter 
has been added covering the observations made 
since the former edition. The present differs from 
the preceding one chiefly in these alterations and 
in about ten pages of useful tables added in the 
appendix — Am. Jo-urn. of Pharmacy, May, 1879. 

A standard work like Attfield's Chemistry need 
only be mentioned by its name, without further 
comments. The present edilion contains such al- 
terations and additions as seemed necessary for 
the demonstration of the latest developments of 



of chemistry in all the medical colleges in the 
United States. The present edition contains such 
alterations and additions as seemed necessary for 
the demonstration of the latest developments of 
chemical principles, and the latest applications of 
chemistry to pharmacy. It is scarcely necessary 
for us to say that it exhibits chemistry in its pre- 
sent advanced state. — Cincinnati Medical News, 
April, 1879. 

The popularity which this work has enjoyed is 
owing to the original and clear disposition of the 
facts of the science, the accuracy of the details, and 
the omission of much which freights many treatises 
heavily without bringing corresponding instruction 
to the reader. Dr. Attfield writes for students, and 
primarily for medical students; he always has an 
eye to the pharmacopoeia and its officinal prepara- 



chemical principles, and the latest applications of ] tions ; and he is continually putting the matter in 



chemistry to pharmacy. The author has bestowed 
arduous labor on the revision, and the extent of 
the information thus introduced may be estimated 
from the fact that the index <-ontains three hun- 
dred new references relating to additional mater- 
ial. — Druggists' Circular and Chemical Gazette. 
May, 1S79. 

This very popular and meritorious work has 



the text so that it responds to the questions with 
which each section is provided. Thus the student 
learns easily, and can always refresh and test his 
knowledge. — Med. and Surg. Reporter, April 19, '79. 
We noticed only about two years and a half ago 
the publication of the preceding edition, and re- 
marked upon the exceptionally valuable character 
of the work. The work now includes the whole of 



now reached its eighth edition, which fact speaks the chemistry of the pharmacopoeia of the United 
in the highest terms in commendation of its excel- States, Great Britain, and India. — New Remedies, 
lence. It has now become the principal text-book • May, 1879. 



G 



REENE [WILLIAM H.), M.D.. 

Demonstrator of Chemistry in Med. Dept., Univ. of Penna. 

A MANUAL OF MEDICAL CHEMISTRY. For the Use of Students. 

Based upon Bowman's Medical Chemistry. In one royal 12mo. volume of 312 pages 
With illustrations. Cloth, $1 75. {Now Ready.) 



It is well written, and gives the latest views on 
vital chemistry, a subject with which most physi- 
cians are not sufficiently familiar. To those who 
may wish to impro-ve their knowledge in that direc- 
tion, we can heartily recommend this work as being 
worthy of a careful perusal. — Phila.Med. and Surg. 
Reporter, April 24, 18S0. 



The little work before us is one which we think 
will be studied with pleasure and profit. The de- 
scriptions, though brief, are clear, and in most cases 
sufficient for the purpose. This book will, in nearly 
all cases, meet general approval. — Am. Journ. of 
Pharmacy, April, 1SS0. 



ffLASSEN (ALEXANDER), 

^ Professor in the Royal Polytechnic School, Aixla-ChapelU. 

ELEMENTARY QUANTITATIVE ANALYSIS. Translated with 

notes and additions by Edgar F. Smith, Ph.D., Assistant Prof, of Chemistry in the 
Towne Scientific School, Univ. of Penna. In one handsome royal 12tno. volume, of 324 
pages, with illustrations ; cloth, $2 00. {Lately Issued.) 

It is probably the best manual of an elementary ] advaucing to the analysis of minerals and such pro- 
nature extant, insomuch as its methods are the best, j ducts as are met with in applied chemistry. It is 
It teaches by examples, commencing with single | an indispensable book for students in chemistry.—* 
determinations, followed by separations, and then i Boston Journ. of Chemistry, Oct. 187S. 



G 



ALLOWAY (ROBERT), F.C.S., 

Prof, of Applied Chemistry in the Royal College of Science for Ireland, etc. 

A MANUAL OF QUALITATIVE ANALYSIS. From the Fifth Lon- 
don Edition. In one neat royal 12mo. volume, with illustrations ; cloth, $2 75. 



TfEMSEN(IRA), M.D., Ph.D., 

Professor of Chemistry in the Johns Hopkins University, Baltimore. 

PRINCIPLESOF THEORETICAL CHEMISTRY, with special reference 

to the Constitution of Chemical Compounds. In one handsome royal 12mo. vol. of over 
232 pages: cloth, $1 50. 



BOWMAN'S INTRODUCTION TO PRACTICAL 
CHEMISTRY, INCLUDING ANALYSIS. Sixth 
American, from the Sixth and revised London edi- 
tion. With numerous illustrations. In one neat 
vol., royal 12mo., cloth, $2 25. 



WOHLER AND FITTIG'S OUTLINES OF ORGANIC 
CHEMISTRY. Translated, with additions, from the 
Eighth German Edition. By Ira Remsen. M D., 
Ph.D., Prof, of Chemistry and Physics in Williams 
College, Mass. In one volume, royal 12mo. of 590 
pp.>cloth,$3. 



10 



Henry C. Lea's Son & Co.'s Publications — (Chemistry}. 



P 



'OWNES [GEORGE), Ph.D. 

A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and 

Practical. Revised and corrected by Henry Watts, B. A., F R.S., author of "A Diction- 
ary of Chemistry," etc. With a colored plate, and one hundred and seventy-seven illus- 
trations. A new American, from the Twelfth and enlarged London edition. Edited by 
Robert Bridges, M.D. In one large royal 12mo. volume, of over 1000 pages; 
cloth, $2 75 ; leather, $3 25. (Lately Issued.) 

what formidable magnitude with its more than a 
thousand pages, but with less than this no fair repre- 
sentation of chemistry as it now is can be given. The 
type is small but very clear, and the sections are very 
lucidly arranged to facilitate study and reference.— 
Med. and Surg. Reporter, Aug 3, 1878. 

The work is too well known to American students 
to need any extended notice; suffice it to say that 
the revision by the English editor has been faithfully 
done, and that Professor Bridges has added some 
fresh and valuable matter, especially in the inor- 
ganic chemistry. The book has always been a fa- 
vorite in this country, and in its new shape bids 
fair to retain all its former prestige. — Boston Jour, 
of Chemistry, Aug. 1878. 

It will be entirely unnecessary for us to make any 
remarks relating to the general character of Fownes' 
Manual. Tor over twenty years it has held the fore- 
most place as a text-book, and the elaborate and 
thorough revisions which have been made from time 
to timeleavelittlechance for any wide awake rival to 
step before it. — Canadian Pharm. Jour., Aug. 1878. 

As a manual of chemistry it is without a superior 
in the language. — Md. Med. Jour., Aug. 1S78. 



This work, inorganic and organic, is complete in 
one convenient volume. In its earliest editions it 
was fully up to the latest advancements and theo- 
ries of that time. In its present form, it presents, 
in a remarkably convenient and satisfactory man- 
ner, the principles and leading facts of the chemistry 
of to-day. Concerning the manner in which the 
various subjects are treated, much deserves to be 
said, and mostly, too, in praise of the book. A re- 
view of such a work as Foivnes's Chemistry within 
the limits of a book-notice for a medical weekly is 
simply out of the question. — Cincinnati Lancet and 
Clinic, Dec. 14, 1S7S. 

When we state that, in our opinion, the present 
edition sustains in every respect tbe high reputation 
which its predecessors have acquired and enjoyed, 
we express therewith our full belief in its intrinsic 
value as a text-book and work of reference. — Am. 
Journ. of Pharm., Aug. 1878. 

The conscientious care which has been bestowed 
upon it by the American and English editors renders 
it still, perhaps, the best book for the student and the 
practitioner who would keep alive the acquisitions 
of his student days. It has, indeed, reached a some- 



B 



LOXAM [C.L.), 

Professor of Chemistry in King's College, London. 

CHEMISTRY, INORGANIC AND ORGANIC. From the Second Lon- 
don Edition. In one very handsome octavo volume, of 700 pages, with about 300 illus- 
trations. Cloth, $4 00 ; leather, $5 00. 



We have in this work a completeand most excel- 
lent text-book for the use of schools, and can heart- 
ily recommend it as such. — Boston Med. and Surg. 
Journ., May 28, 1874. 

The above is the title of a work which we can most 
conscientiously recommend to students of chemis- 
try. It is as easy as a work on chemistry could be I 
made, at the same time that it present sa full account | 
of thatscience as it now stand 
of the work as admirably adapted to the wants of 
students ; it is quite as well suited to the require- 
ments of practitioners who wish to review their 
chemistry, or have occasion to refresh their memo- 
ries on any point relating to it. In a word, it is a 
book to be read by all who wish to know what is 
the chemistry of the present day. — American Prac- 
titioner, Nov. 1873. 



It would be difficult for a practical chemist and 
teacher to find any material fault with this most ad- 
mirable treatise. The author has given us almost a 
cyclopaedia within the limits of aconvenient volume, 
and has done so without penning the useless para- 
graphs too commonly making up a great part of the 
bulk of many cumbrous works. The progressive 
scientist is not disappointed when he looks for tha 

vJt! I record of new and valuable processes and discover- 
vv enavesrjoKen. ,., . .. . ■ t ± n j • . 

les, while the cautious conservative does not find its 

pages monopolized by uncertain theories and specu- 
lations. A peculiar point of excellence is the crys- 
tallized form of expression in which great truths are 
expressed in very short paragra phs. One is surprised 
at the brief space allotted to an important topic, and 
yet, after reading it, he feels that little, if any more 
should have been said. Altogether, it is seldom yoa 
see a text-book so nearly faultless. — Cincinnati 
Lancet, Nov. 1873. 



ftLO WES (FRANK), D.Sc, London. 

V^ Senior Science- Master at the High School, Newcastle-under-Lyme, etc. 

AN ELEMENTARY TREATISE ON PRACTICAL CHEMISTRY 

AND QUALITATIVE INORGANIC ANALYSIS. Specially adapted for Use in the 
Laboratories of Schools and Colleges and by Beginners. Second American from the 
Third and Revised English Edition. In one very handsome royal 12mo. volume of 
372 pages, with 47 illustrations. Cloth, $2 50 

This is a valuable work for those about to com- 
mence chemistry, the more so as by its use they are 
simultaneously acquainted with the manipulation 
of chemical analysis, a method which is the most 
valuable to impart a thor> ugh knrtwlerge of chemis- 
try. It is a very good little book, and will make 
for itself many warm friends and supoorters. It 
treats the subject well and the tables are very clear 
and valuable. — St. Louis Med. and Surg. Journ., 
Mar. 1SSI. 

This work is not only well adapted for use as a 
text-book in medical colleges, but is also one of the 
best that a practitioner can have for convenient re- 



(Just Ready.) 

ference and instruction in his library. As a rule, 
such volumes are too technical and abstruse for 
study without some didactic aid, but the volume 
presented is easy of comprehension, and will be of 
great value to college students and busv practition- 
ers.— N. Y. Am. Med. Bi-Weekly, April 9, 1881. 

The tables particularly demand praise, for they 
are admirably formed, both for convenience of re- 
ference and fulness of information. In short v we 
do not remember to have met with a book which 
could better serve the student as a guide to the svs- 
tematic studv of inorganic chemistry. — Louisville 
Med. News, March 12, 1S81. 



KNAPP'S TECHNOLOGY; or Chemistry Applied to 
the Arts and to Manufactures. With American 
additions by Prof. Walter K. Johnson. In two 



very handsome octavo volumes, with 500 wood 
engravings, cloth, $6 00. 



Henry C. Lea's Son & Co.'s Publications — (Phar., Mat. Med., etc.). 11 



JJOFFMAN {FRED.), Ph.D. and jpo WER [FRED. B.), Ph.D. 

Prof of Anat. Chem. in Phil. Ooll. of Pharmacy 

MANUAL OF CHEMICAL ANALYSIS, as Applied to the Exami- 

nation of Medical Chemicals and their Preparations. Being a Guide for the Determi- 
nation of their Identity and Quality, and for the Detection of Impurities and Adultera- 
tions. For the Use of Pharmacists, Physicians, Druggists and Manufacturing Chemists, 
and Pharmaceutical and Medical Students. Third edition, entirely rewritten and much 
enlarged. In one very handsome octavo volume, fully illustrated. {Preparing.) 

pARRlSH [ED WARD), 

Late Professor of Materia Mediea in the Philadelphia College of Pharmacy. 

A TREATISE ON PHARMACY. Designed as a Text-Book for the 

Stu#ent, and as a Guide for the Physician and Pharmaceutist. With many Formulae and 
Prescriptions. Fourth Edition, thoroughly revised, hy Thomas S. Wiegand. In one 
handsome octavo volume of 977 pages, with 280 illustrations ; cloth, $5 50 ; leather, $6 50; 
half Russia, $7 

Of Dr. Parrish's great work on pharmacy it only j lisher. It willconveysomeideaoftheliberality which 
remains to be said that the editor has accomplished ; has been bestowed upon its production when we men - 
his work so well as to maintain, in this fourth edi- ' tion that there are no less than 2S0 carefully executed 
tion, the high standard of excellence which it bad Illustrations. In conclusion, we heartily recommend 
attainedin previous editions, under theeditorship of the work, not only to pharmacists, but also to the 
its accomplished author. This has not been accom- multitude of medical practitioners who are obliged 
plished without much labor, and many additions and to compound their own medicines. It will ever hold 

an honored place on our own bookshelves. — Dublin 
Med. Press and Circular, Aug. 12, 1874. 

Perhaps one, if not the most important book upon 
pharmacy which has appeared in the English lan- 
guage has emanated from the transatlantic press. 
"Parrish's Pharmacy" is a well-known work on this 
side of the water, and the fact shows us that a really 
useful work never becomes merely local in its fame. 
Thanks to the j ndicious editing of Mr. Wiegand, the 
posthumous edition of "Parrish" has been saved to 



improvements, involving changes in the arrange- 
mentof the several parts of the work, and the addi- 
tion of much new matter. With the modifications 
thus effected it constitutes, as now presented, a com- 
pendium of the science and art indispensable to the 
pharmacist, and of the utmost value to every 
practitioner of medicine desirous of familiarizing 
himself with the pharmaceutical preparation of the 
articles which he prescribes for his patients. — Chi- 
cago Med. Journ., July, 1874. 

The work is eminently practical, and has the rare the public with all the mature experienceof its~an 
merit of beiug readable and interesting, while it pre- thor, anil perhaps none the worse for a dash of new 
serves a strictly scientiflccharaoter. The whole work blood. — Lond. Pharm. Journal, Oct. 17, 1874. 
reflects the greatest credit on author, editor, and pub- 



G 



RIFFITH (ROBERT E.), M.D. 

A UNIVERSAL FORMULARY, Containing the Methods of Prepar- 
ing and Administering Officinal and other Medicines. The whole adapted to Physiciars and 
Pharmaceutists. Third edition, thoroughly revised, with numerous additions, bj John M. 
Maisch, Professorof Materia Medicain the Philadelphia Collegeof Pharmacy. In one large 
and handsome octavo volume of about 800 pages. Cloth, $4 50 ; leather $5 50. 
A more complete formulary than it is in its pres • I mitted to memory by every student of medicine- 
ent form the pharmacist or physician could hardly I As a help to physicians it will be found invaluable 
desire. To the first some such work is indispensa [and doubtless will make its way into libraries do' 
ble, and it is hardly less essential to the practitionei : already supplied with a standard work of the kind 
who compounds his own medicines. Much ofwhat \— The American Practitioner , Louisville, July '74 
is contained in the introduction ought to be com- I ' 



F 



ARQUHARSON (ROBERT), M.D. , 

Lecturer on Materia Mediea, at St. Mary's Hospital Medical School. 

A GUIDE TO THERAPEUTICS AND MATERIA MEDICA. Se- 
cond American edition, revised by the Author. Enlarged and adapted to the U. S. 
Pharmacopoeia. By Frank Woodbury, M.D. In one neat royal 12mo. volume of 498 
pages: cloth, $2.25. (Lately Issued.) 

The appearance of a new edition of this conve- i copious notes have been introduced, embodying the 
nient and handy hook in less than two years may | latest revision of the Pharmacopoeia, together with 
certainly be taken as an indication of its useful- ' the antidotes to the more prominent poisons, and 
ness. Its convenient arrangement, and its terse- | such of the newer remedial airents as seemed n'eces- 
ness, and, at the same time, completeness of the j sary <-o the completeness of the work. Tables of 
information given, make it a handy book of refer- ' weights and measures, and a good alphabetical in- 
Bnee.—Am. Journ. of Pharmacy, June, 1879. | dex end the volume —Druggists' Circular and 

This work contains in moderate compass such Chemical Gazette, June, 1879. 
well-digested facte concerning the physiological j It is a pleasure to think that the rapidity with 



and therapeutical action of remedies as are reas 
ably established up to the present time. By a con- j 
venient arrangement the correspondirg effects of 
each article in health and disease are presented in 
parallel columns, not only rendering reference 
easier, but also impressing the facts more strongly 



which a second edition is demanded may be taken 
as an indication thatthe sense of appreciation of the 
value of reliable information regarding the use of 
remedies is not entirely overwhelmed in the cultiva- 
tion of pathologicalstu'dies, characteristic of the pre- 
sent day. This work certainly merits the success it 



upon the mind of the reader. The book has been has so quickly achieved.— New Remedies, July, '79 
adapted to the wants of the American student, and i 



CHRISTISON'S DISPENSATORY. With copious ad- 
ditions, and 213 larare wood engravings. By R. 
Ehlesfield Griffith, M.D. One vol. 8vo., pp. 
1000 cloth, $4 00. 



CARPENTER'S PRIZE ESSAY ON THE USE OF 
Alcoholic Liquors in Health and Disease. New 
edition, with a Preface by D. F.Condie. M D.,and 
explanations of scientificwords. In oneneatl2mo. 
volume, pp. 178, cloth, 60 cents. 



12 Henry C. Lea's Son <fe Co.'s Publications — (Mat. Med. and Therap.). 



UTILLE {ALFRED), M.D., LL.D., and JlfAISGH {JOHN M.), Ph.D., 

A3 Prof .of Theory and Practice of Medicine -*-*-*- Prof.ofMat.Med.a.ndBot.inPhila. 

and of Clinical Med. in Univ. of Pa. Coll. Pharmacy, Secy, to the American 

Pharmaceutical Association. 

THE NATIONAL DISPENSATORY: Containing the Natural History, 

Chemistry, Pharmacy, Actions and Uses of Medicines, including those recognized in 
the Pharmacopoeias of the United States, Great Britain and Germany, with numer- 
ous references to the French Codex. Second edition, thoroughly revised, with numerous 
additions. In one very handsome octavo volume of 1692 pages, with 239 illustrations. 
Extra cloth, $6 75; leather, raised bands, $7 50; half Russia, raised bands and open 
back, $8 25. (Now Ready.) 

Preface to the Second Edition. 

The demand which has exhausted in a few months an unusually large edition of the National 
Dispensatory is doubly gratifying to the authors, as showing that they were correct in thinking 
that the want of such a work was felt by the medical and pharmaceutical professions, and that 
their efforts to supply that want have been acceptable. This appreciation of their labors has 
stimulated them in the revision to render the volume more worthy of the very marked favor 
with which it has been received. The first edition of a work of such magnitude must necessarily 
be more or less imperfect ; and though but little that is new and important has been brought 
to light in the short interval since its publication, yet the length of time during which it was 
passing through the press rendered the earlier portions more in arrears than the la L er. The 
opportunity for a revision has enabled the authors to scrutinize the work as a whole, and to 
introduce alterations and additions wherever there has seemed to be occasion for improve- 
ment or greater completeness. The principal changes to be noted are the introduction of seve- 
ral drugs under separate headings, and of a large number of drugs, chemicals and pharma- 
ceutical preparations classified as allied drugs and preparations under the heading of more 
important or better known articles : these additions comprise in part .nearly the entire German 
Pharmacopoeia and numerous articles from the French Codex. All new investigations which 
came to the authors' notice up to the time of publication have received due consideration. 

The series of illustrations has undergone a corresponding thorough revision. A number have 
been added, and still more have been substituted for such as were deemed less satisfactory. 

The new matter embraced in the text is equal to nearly one hundred pages of the first edition. 
Considerable as are these changes as a whole, they have been accommodated by an enlargement 
of the page without increasing unduly the size of the volume. 

While numerous additions have been made to the sections which relate to the physiological 
action of medicines and their use in the treatment of disease, great care has been taken to 
make them as concise as was possible without rendering them incomplete or obscure. The 
doses have been expressed in the terms both of troy weight and of the metrical system, for the 
purpose of making those who employ the Dispensatory familiar with the latter, and paving the 
way for its introduction into general use. 

The Therapeutical Index has been extended by about 2250 new references, making the total 
number in the present edition about 6000. 

The articles there enumerated as remedies for particular diseases are not only those which, 
in the authors' opinion, are curative, or even beneficial, but those also which have at anytime 
been employed on the ground of popular belief or professional authority. It is often of as 
much consequence to be acquainted with the worthlessness of certain medicines or with the 
narrow limits of their power, as to know the well attested virtues of others and the conditions 
under which they are displayed. An additional value possessed by such an Index is, that it 
contains the elements of a natural classification of medicines, founded upon an analysis of the 
results of experience, which is the only safe guide in the treatment of disease. 

keep the work up to the time. — New Remedies, Nov. 
1879. / 



This evidence of success, seldom paralleled, 
shows clearly how well the authors have met the 
existing needs of the pharmaceutical and medical 
professions. Gratifying as it must be to them, they 
have embraced the opportunity offered for. a thor- 
ough revision of the whole work, striving to em- 
brace within it all that might have been omitted in 
the former edition, and all that has newly appeared 
of sufficient importance during the time of its col- 
laboration, and the short interval elapsed since the 
previous publication. After having gone carefully 
through the volume we must admit that the authors 
have labored faithfully, and with success, in main- 
taining the high character of their work as a com- 
pendium meeting the requirements of the day, to 
which one can safely turn in quest of the latest in- 
formation concerning everything worthy of notice in 
connection with Pharmacy, Materia Medica, and 
Therapeutics. — Am. Jour, of Pharmacy, Nov. 1879. 

It is with great pleasure that we announce to our 
readers the appearance of a second edition of the 
National Dispensatory. The total exhaustion of the 
first edition in the short space of six months, is a 
sufficient testimony to the value placed upon the 
work by the profession. It appears that the rapid 
sale of the first edition must have induced both the 
editors and the publisher to make preparations for 
a new edition immediately after the first had been 
issued, for we find a large amount of new matter 
added and a good deal of the previous text altered 
and improved, which proves that the authors do not 
intend to let the grass grow under their feet, but to 



This is a great work by two of the ablest writers on 
materia medica in America The authors have pro- 
duced a work which, for accuracy and comprehensive- 
ness, is unsurpassed by any work on the subject There 
is no book in the English language which contains so 
much valuable information on the various articles of 
the materia medica. . The work has cost the authors 
years of laborious study, but they have succeeded in 
producing a dispensatory which is not only national, 
but will be a lasting memorial of, the learning and 
ability of the authors who produced it. — Edinburgh 
Medical Journal, Nov. 1879. 

It is by far more international or universal than 
any other book of the kind in our language, and 
more comprehensive in every sense.— Pacific Med. 
and, Surg. Journ., Oct. 1879. 

The National Dispensatory is beyond dispute the 
very best authority. It is throughout complete in 
all the necessary details, clear and lucid in its ex- 
planations, and replete with references to the most 
recent writings, where further particulars can be 
obtained, if desired. Its value is greatly enhanced 
by the extensive indices — a general index of materia 
medica, etc., and also an index of therapeutics. It 
would he a work of supererogation to say mora about 
this well-known work. No practising physician can 
afford to be without the National Dispensatory.— 
Canada Med. and Surg. Journ., Feb. 1880. 



Henry C. Lea's Son & Co.'s Publications — (Mat. Med.,Therap.,etc). 13 

IF 



AISCH (JOHN M,), Plxar. D., 

Prof, of Materia Medica and Botany in the Phila. CoV. of Pharmacy, 

A MANUAL OF ORGANIC MATERIA MEDTCA. 



Being a Guide 



to Materia Medica of the Vegetable and Animal Kingdoms. For the use of Students, 
Druggists, Pharmacists and Physicians. In one handsome 12mo. volume, with numer- 
ous illustrations on wood. {Preparing.) % 

EXTRACT FROM THE AUTHOR'S PREFACE. 

When in 1866 the author was called to the chair of Materia Medica in the institution named 
(the Philadelphia College of Pharmncy), he seriously felt the need of a suitable text book 
which could be used in connection with hi? lectures, and made preparations for the publication 
of such a work at an early date. To elaborate a system of classification, which should be with- 
out difficulty comprehended and readily applied by those for whom it was intended, was by no 
means an easy task, and the author found occasion, almost every year, to either remodel that 
previously selected, or to make what in his opinion seemed to be desirable improvements. The 
publication of the " National Dispensatory" in a measure supplied the want felt, at least as far 
as a work of reference is conferred, but owing to its local arrangement, it is not adapted to 
systematic instruction. However, its publication rendered a modification of the original plan 
for a treatise on Materia Medica desirable, and it is now presented in a form giving an outline 
of the substance of the lectures and embracing what are considered the essential physical, histo- 
logical, and chemical characters of the organic drug, so as to render the work also a useful and 
reliable guide in business transactions. Regarding the classification, the author is conscious 
of its imperfections, but he believes it to be convenient and capable of practical application. 

In reference to the scope of the work, the main aim has been to embrace all the drugs recog- 
nized by the U. S. Pharmacopoeia, together with the old, but now unofficinal ones, and such 
others, the use of which has been recently revived or suggested, and which seem to deserve 
attention. The medical properti-s and doses of the various drugs are merely briefly stated as 
subjects of general important information ; tlie present work is not intended for giving instruc- 
tion in the therapeutic application of drugs. 



UTILLE (ALFRED), M.D., 

Professor of Theory and Practice of Medicine in the University of Penna . 

THERAPEUTICS AND MATERIA MEDICA ; a Systematic Treatise 

on the Action and Uses of Medicinal Agents, including their Description and History. 
Fourth edition, revised and enlarged. In twolarge and handsome 8vo. vols, of about2000 
pages. Cloth, $10; leather, $12; half Russia, $13. 



It is unnecessary to do much more than to an- 
nounce the appearance of the fourth edition of this 
well known and excellent work. — Brit, and For. 
Med.-Chir. Review, Oct 1875. 

For all who desire a complete work on therapeu- 
tics and materia medica for reference, in cases in- 
volving medico-legal questions, as well as foi in- 
formation concerning remedial agents, Dr. St i lie's is 
"par excellence?' the work. Beingout of print, by 
the exhaustion of former editions, the author has laid 
the profession under renewed obligations, by the 
careful revision, importantadditions, and timely re- 
issuing a work not exactly supplemented by any 
other in the English language, if in any language. 
The mechanical execution handsomely sustains the 
well-known skill and good taste of the publisher. — 
St. Louis Med. and Surff. Journal, Dec. 1S74. 

From the publication of the first edition "StillS's 
Therapeutics" has been one of the classics; its ab- 
sence from our libraries would create a vacuum 
which could be filled by no other work in the lan- 
guage, and its presence supplies, in the two volumes 



of the present edition, a whole cyclopaedia of thera- 
peutics.— Chicago Medical Journal, Feb. 1S75. 

The rapid exhaustion ofthreeeditions and the uni- 
versal favor with which the work has been received 
by the medical profession, are sufficient proof of its 
excellence as a repertory of practical and useful in- 
formation for the physician. The edition before us 
fully sustains this verdict, as the work has been care- 
fully revised and in some portions rewritten, bring- 
ing it up to the present time by the admission of 
chloral and croton-chloral, nitrite of amyl, bichlo- 
ride of methylene, methylic ether, lithium com- 
pounds, gelseminum, and other remedies. — Am. 
Journ. of Pharmacy, Feb. 1S75. 

We can hardly admit that it has a rival in the 
multitade of its citations and the fulness of its re- 
search into clinical histories, and we must assign it 
a place in the physician's library; not, indeed, as 
fully representing the present state of knowledge in 
pharmacodynamics, but as by far the most complete 
treatise upon the clinical and practical side of the 
question. — Boston Med. and Surg. Journal, Nov . 5, 



(10RNIL (V.), AND 

^ Prof, in the Faculty of Med., Paris. 



TfANVIER (L.), 

-*- 1* Prof in the College of France. 

MANUAL OF PATHOLOGICAL HISTOLOGY. Translated, with 

Notes and Additions, by E. 0. Shakespeare, M.D., Pathologist and Ophthalmic Surgeon 
to Philada. Hospital, Lecturer on Refraction and Operative Ophthalmic Surgery in Univ. 
of Penna., and by Henry C. Simes. M D., Demonstrator of Pathological Histology in 
the Univ. of Pa. In one very handsome octavo volume of over 700 pages, with over 
350 illustrations. Cloth, $5 50; leather, $6 50 ; half Russia, $7. (Just Ready.) 
We have no hesitation in cordially recommending 
the English translation ofCornil & Ranvier's "Pa- 
thological Histology" as the best work of the kind 
in any language, and as giving to its readers a 
trustworthy guide in obtaining a broad and solid 



isis for the appreciation of the practical bearings 
of pathological anatomy. — Am. Journ. of Med. 
Sciences, Aoril, 1880. 

This important work, in its American dress, is a 
welcome offering to all students of the subjects 
which it treats. The great mass of material is 
arranged naturally and comprehensively. The 
classification of tumors is clear and full, so far as 



the subject admits of definition, and this one chap- 
ter is worth the price of the book. The illustra- 
tions are copious and well chosen. Without the 
slightest hesitation, the translators deeerve honest 
thanks for placing this indispensable work in the 
hands of American students.— Phila. Med. Times, 
April 24, 1S80 

This "dume we cordially commend to theprofes- 
sion. It will prove a valuable, almost necessary, 
addition to the libraries of students who are to be 
physicians, and to the libraries of students who are 
physicians.— American Practitioner, June, 1SS0. 



14 Henry C. Lea's Son & Co.'s Publications — (Pathology, etc.). 
J^ENWICK (SAMUEL), M.D., 

-*■ Assistant Physician to the London Hospital., 

THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the 

Third Revised and Enlarged English Edition. With eighty-four illustrations on wood. 
In one very handsome volume, royal 12mo. , cloth, $2 25. {Lately Issued.) 

ft RE EN (T. HENRY), M.D., 

*-" Lecturer on Pathology and Morbid. Anatomy at Charing-Cross Hospital Medical School, etc. 

PATHOLOGY AND MORBID ANATOMY. Fourth American, from 

the Fifth Enlarged and Revised English Edition. In one very handsome octavo volume 
of about 350 pages, with 138 fine engravings; cloth, $2 25. {Just Ready.) 
Extract from the Author's Preface. 
In preparing the fifth edition of my Text-book on Pathology and Morbid Anatomy, I have 
again added much new matter, with the object of making the work a more complete guide for 
the student. All the chapters have been carefully revised, some alterations have been made in 
the arrangement of the work, and an addition has been made to the number of wood-cuts. The 
new wood cuts, as in previous editions, have been drawn by Mr. Collings from my own micro- 
scopical preparations. 



We have long considered this the best guide yet 
presented to the student for the identification of va- 
rious morbid tissues. We hive found it more satis- 
factory than any other. The present edition has 



been thoroughly revised, and much new matter 
has been ?dded. To the physician as a guide in 
diagnosis, we recommend this volume. — Physician 
and Surgeon, May, 1S81. 



RRISTO WE (JOHN SYER), M.D., FR.C.P., 

Physician and Joint Lecturer on Medicine, St. Thomas's Hospital. 

TREATISE ON THE PRACTICE OF MEDICINE. Second 

American edition, revised by the Author. Edited, with Additions, by James H. Hutch- 
inson, M.D., Physician to the Penna. Hospital. In one handsome octavo volume of 
nearly 1200 pages. With illustrations. Cloth, $5.00; leather, $6 00; half Russia, 



A 



$6 50. {Now Ready.) 

The second edition of this excellent work, lite the 
first, has received the benefit of Dr. Hutchinson's 
annotations, by -which the phases of disease which 
are peculiar to this country are indicated, and thus 
a treatise which was intended for British practi- 
tioners and students is made more practically useful 
on this side of the water. We see no reason to 
modify the high opinion previously expressed with 
regard to Dr. Bristowe's work, except by adding 
our appreciation of the careful labors of the author 
in following the lateral growth of medical science. 
— Boston Medical and Surgical Journal, February, 
1 S«0 

What we said of the first edition, we can, with 
increased emphasis, repeat concerning this: "Every 
page is characterized by the utterances of a thought- 
ful man. What has been said, has been well said, 
and the book is a fair reflex of all that is certainly 
kn.^vjn on the sub'ects considered." — Ohio Med 
Recorder, Jan. 7, 1880. 



The views of the author are expressed with preci- 
sion and sufficient promptness to impress the student 
with the weight of his authority; and should the 
medical professor differ on any subject from his doc- 
trine, he will need to find strong arguments to carry 
his class to the opposite conclusion. — N. O. Med. and 
Surg. Journ , 'Feb. 1880. 

The reader will find every conceivable subject 
connected with the practice of medicine ably pre- 
sented, in a style at once clear, interesting, and con- 
cise. The additions mide by Dr. Hitchinson are 
appropriate and practical, and greatly add to its 
usefulness to American readers. — Buffalo Med. and 
Surg. Journ., March, 18S0. 

We regard it as an excellent work for students and 
for practitioners. It is clearly written, the author's 
style is attractive, and it is especially to be com- 
mended for its excellent exposition of the pathol igy 
and clinical phenomena of disease. — St. Louis Clin. 
Record, Feb. 1SS0. 



H 



ABERSHON (S. O.) M.D. 

Senior Physician to, and late Lecturer on the Principles and Practice of Medicine at, Guy's 
Hospital, etc. 

ON THE DISEASES OF THE ABDOMEN, COMPRISING THOSE 

of the Stomach, and other parts of the Alimentary Canal, Oesophagus, Caecum, Intes- 
tines and Peritoneum. Second American, from the Third enlarged and revised Eng- 
lish edition. With illustrations. In one handsome octavo volume of over 500 pages. 
Cloth, $3 50. {Lately Issued.) 

amended by the author. Several new chapters have 
been added, bringing the work fully up to the times, 
and making it a volume of interest to the practi- 
tioner in every field of medicine and surgery. Per- 
verted nutrition is in some form associated with all 
diseases we have to combat, and we need all the 
light that can ^e obtained on a subject so broad and 
general. Dr Habershon's work is one that every 
practitioner sh mid read and study for himself. — 
N. Y. Med. Journ , April, 1879. 



This valuable treatise on diseases of the stomach 
and abdomen has been ont of print for several years, 
and is therefore not so well known to the profession 
as it deserves to be. It will be found a cyclopedia 
of information, systematically arranged, on all dis- 
eases of the alimentary tract, from the mo'ith to the 
rectum A fair proportion of each chapter is devoted 
to symptoms pathology, and therapeutics. The 
present edition is fuller than former ones in many 
particulars, and has been thoroughly revised and 



GLUGE'S ATLAS of PATHOLOGICAL HISTOLOGY. 
Translated, with Notes and Additions, by Joseph 
Leidy, M. D. In one volume, very large imperial 
quarto, with 320 copper-plate figures, plain and 
colored, cloth. $4 00. 

LA ROCHE ON YELLOW FEVER, considered in its 
Historical, Pathological, Etiological and Thera- 
peutical Relations. In two large and handsome 
octavo volumes of nearly 1.500 pp. , cloth. $7 00. 

STOKES' LECTURES ON FEVER. Edited by John 
William Moore, M. D., Assistant Physician to the 
Cork Street Fever Hospital. In one neat 8vo. 
volume, cloth, $2 00. 



PAVY'S TREATISE ON THE FUNCTION OF DI- 
GESTION: its Disorders and their Treatment. 
From the Second London edition. In one hand- 
some volume, small octavo, cloth, $2 00. 

HOLLAND'S MEDICAL NOTES AND REFLEC- 
TIONS. 1 vol 8vo., pp. 500, cloth. $3 50 

BARLOW'S MANUAL OF THE PRACTICE OF 
MEDICINE. With Additions by D. F.Condie, 
MD 1 vol. Rvo., pp.600, cloth. «2 50. 

TODD'SCLINICAL LECTURES on CERTAIN ACUTE 
Diseases. In one neat octavo volume, of 320 pp. 
cloth. $2 60. 



Henry C. Lea's Son & Co.'s Publications — {Practice of Medicine). 15 



WLINT (A USTJN), M.D., 

•J- Professor of the Principles and Practice of Medicine in Bellevue Med. College, N. Y. 

A TREATISE ON THE PRINCIPLES AND PRACTICE OF 

MEDICINE ; designed for the use of Students and Practitioners of Medicine. Fifth 
edition, entirely rewritten and mu^h improved. In one large and closely printed octavo 
volume of 1153 pp. Cloth, $5 50; leather, $6 50: very handsome half Russia, raised 
bands, $7. (Just Ready.) 



This work has been so loDg ind favorably known, 
and has obtained so high a position amongst mod- 
ern treatises on medicine, that it is hardly neces- 
sary to do more than announce the pn&lication of 
this fifth edition. All who peruke it mast be -trnck 
by the extensive research which has been under- 
taken in the revision of this edition, combined wiih 
much original thought There is hardly a subject 
which does not receive fresh illustration and discus- 
siou, opening up new lines of inquiry which ha 1 not 
been thought of when the previous edition appeared. 
We cannot conclude this ootice without expressing 
our admiration of this volume, which is certaiuly 
one of the standard t«Xt-books on medicine, and we 
may safely affirm that, taken altogether, it exhihits 
a fuller and wider acquaintance with r>cent patho- 
logical inquiry than any similar work with which 
we are acquainted, whilst at the same time it shows 
its author to be possessed of the rare facilities of 
clear exposition, thoughtful discrimination, and 
sound judgmeut. — London Lancet, July 23, 1SS1. 

Practically, this edition is a new work ; for so 
many additions and changes have been made that 
one well acquainted with previous editions would 
hardly recognize this as an o'd friend The size of 
the volume is somewhat increased. An entire new 
section and several new chapters have been added. 
It is universally conceded that no text book upon 
this subject was ever published in this country 
that can at all compare with it It has long been 
at the very head of American text book literature, 
and there can be no doubt bu: that it will be many 



years before it yields the place to others. — Nash- 
ville. Joi/.rn. of Mul. and Surg , Feb. 1SS1. 

'• Flint's Practice"' is recognized to be a standard 
treatise of high raDk upon the principles and the 
practice of medicine wherever the English lauguage 
is read. The opinions everywhere reveil the man 
of extensive experience, dilisrent study, calm judg- 
ment, and unbiassed criticism. The work should 
be in the hands of every practitioner. — New Turk 
Med. Record, Feb. 26, 1881. 

The style and character of this work are too well 
known to the profession to require an introduction. 
For a number of years this volume has occupied a 
leading psimn as a text-book in the majority of 
medical schools, aud the high position accorded to 
it in the past is a guarantee of a hearty welcome in 
this new edition The book may be said to represe: t 
the present state of the science of medicine as now 
understood and taught. It is a safe guide lo students 
and practitioners of medicine. — Maryland Medical 
Journal. March 1, 1881. 

The authoi- has. in this edition, revised and re- 
written a great oart and mide it accord with the 
more advanced idea* wh'ch have been developed 
withiu the past few years. He is 'he more fitted to 
do so, as he is actively engaged in his profession, 
and can make deductions, not from the work of 
others, bat from his own labors. It is a treatise 
wnich every American physician should have upon 
his table, and which he should consult on occasions 
wlieu his leisure permits him to do so. — St. Louis 
Mud and S'irg. Journal, March, 1881. 



Y THE SAME AUTHOR. 

CLINICAL MEDICINE; a Systematic Treatise on the Diagnosis 

and Treatment of Diseases. Designer! for Students and Practitioners of Medicine. In 
one large and handsome octavo volume of 795 pages; cloth, $4 50 ; leather, $5 50; 
half Russia, $6. (Now Ready.) 

in this country as that of the author of two works 
of great merit on special subjects, aud of numerous 
papers, exbib'ting much originality and extensive 
res arch.— The Dublin Journal, Dec. 1S79. 

There is every reasou to believe that this book 
will be well received. The active practitioner is 
frequently in need of some work that will enable 
him to obtain information in the diagnosis and 
treatment of cases with comparatively little labor. 
Dr. Flint has the facul'y of expressing himself 
clearly, and at the same time so concisely as to 
enable the searcher to traverse the entire ground 
of his searcl 
is essen ti il, 
nab'e space 

The great object is to place before the reader the 
latest observations and experience in dinguosis and 
treat nent. Such a w >rk is especially valuable to 
students. It is complete in Us special design, and 
yet so condensed, that he can by its aid, keep up 



The eminent teacherwho has written the volume 
under consideration h^s recognized the needs of 
the American profession, aud thf result is all that 
we could wish. The style in which it i' wnt'en is 
peculiarly the author's; it is clear and forcible, and 
marked by those characteristics which have ren- 
dered him one of the best writers and teachers this 
country has ever produced. We have not space for 
so full a consideration of this remarkable work as 
we would desire. — St. Louis Clin. Record, Oct. 1879. 

It is here that the skill and learning of the great 
clinician are displayed He has giveu us a store- 
house of medical knowledge, excellent for the stu- 
dent, convenient for the practitioner, the result of a 
long life of the most faithful clinical work, collect- 
ed by an energy as v'gilant find systematic as un- 
tiring, and weighed by a judgment no less clear 
than his observation is close. — Archives of Medi- 
cine, Dec. 1S79 

of the 



md at the same time obtain all that 
ithont plodding through an intermi- 
N. Y. Mf.d. Jour.. Nov. 1S79 



To give an adequate and useful con-pectu 
extensive field of modern clinical medicine is a task j with the lectures on practice without neglecting 
of # no ordinary difficulty ; bat to accomplish this | orher branches. It will not esc ipe the notice of the 
consistently, wilh brevity and clearness, the diff^r^nt I practitioner that such a work is most valuable in 
subjects and their several parts receiving the atten- l cuLiug points in diagnosis and treatment in the iu- 
tiou which, relatively to their importance, medical I tervals between the daily rounds of visits, since he 
opinion claims for them, is still more difficult. This I can in a few minutes refresh his memory, or learn 
tisk we feel bound to say has been executed wi'h the litest advauce in the treatment of diseases which 
more than partial success by Dr Flint, whose name I demand his instant a tentien. — Cincinnati Lancet 
i6 already familiar to students of advanced medicine i and Jlinic, Oct. 25, 1S79. 



JD Y THE SA ME A UTHOR. 

ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED 

TOPICS. In one very handsome royal 12mo. volume. Cloth, $1 38. (Just Issued.) 



DAVIS'S CLINICAL LECTURES ON VARIOUS 
IMPORTANT DISEASES; being a collection of the 
Clinical Lectures delivered in the Medical Wards 
of Mercy Hospial, Chicago. Edited by Frank H 
Davis. M. D. Second edition, enlarged. In one 
handsome royal 12oio. volume. Cloth, $1 75. 



STURGES'S INTRODUCTION TO THE STUDY OF 
CLINICAL MEDICINE. Being a Guide to the In 
vestigation of Disease. In one handsome 12mo. 
volume, cloth, $1 25. 



16 Henry C. Lea's Son & Co.'s Publications — {Practice of Medicine). 



RICHARDSON (BENJ. W.), M.D., F.R.S., M.A., LL.D. 

•*-* J Fellow <>f the Royal College of Physicians, London. 



F.S.A. 



PREVENTIVE MEDICINE. 

(Shortly.) 



In one octavo volume of about 500 pages. 



LJARTSHORNE {HENRY), M.D., 

•*■-*■ Professor of Hygiene in the University of Pennsylvania ■ 

ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDI- 

CINE. A handy book for Students and Practitioners Fifth edition, thoroughly re- 
vised and rewritten. With 140 illustrations. In one handsome royal 12mo. volume, of 
about 600 pages. (In Press.) 
The very great success which has exhausted four large editions of this work shows that the 
author has succeeded in supplying a want felt by a large portion of the profession. It has also 
enabled him in successive revisions to perfect the details of his plan, and to render the work 
still more worthy of the favor with which it has been received. The present edition has had 
sedulous attention at the hands of the author to bring it in every way on a level with the most 
advanced condition of the subject, and no effort has been spared to make the volume worthy a 
continuance of the very great favor with which it has hitherto been received. 

MTOODBURY (FRANK), M.D., 

' * Physician to the German Hospital, Philadelphia, late Chief Assist, to Med. Clinic, Jeff. College 

Hospital, etc. 

A HANDBOOK OF THE PRINCIPLES AND PRACTICE OF 

Medicine ; for the use of Students and Practitioners. In one neat volume, royal 12mo., 
with illustrations. (In Press.) 



TjWTRERGlLL (J. MILNER),M.D. Edin., M.R.C.P. Lond., 

-*- Asst. Phys. to the West Lond. Hosp. : Asst. Phys. to the City of Lond. Hosp.,etc. 

THE PRACTITIONER'S HANDBOOK OF TREATMENT; Or, the 

Principles of Therapeutics. Second edition, revised and enlarged. In one very neat 
octavo volume of about 650 pages. Cloth, $4 00; very handsome half Russia, $5 50. 
(Just Ready.) 

to the thoughtful reader all the charms and beau- 
ties of a well-written novel. No physician can 
well afford to be without this valuable work, for its 
originality makes it fill a niche in medical litera- 
ture hitherto vacant. — Nashville Journ. of Med. 
and Surg., Oct. 1SS0. 

Throughout the work, while room is left for dif- 
ference of opiuion in matters of detail, the main 
courses of treatment are so carefully founded on 
well-established principles, that no essential dif- 
The author merits the thanks of every well-edu- ference is felt to be possible. The closing chapter 



The junior members of the profession will find in 
it a work that should not only be read, but care- 
fully studied. It will assist them in the proper 
selection and combination of therapeutical agents 
best adapted to each case and condition, and enable 
them to prescribe intelligently and successfully. 
To do full justice to a work of this scope aud char- 
acter will be impossible in a review of this kind. 
The book itself must be read to be fully appreciated. 
— St. Louis Courier of Medicine, Nov. 1SS0. 



cated physician for his efforts toward rationalizin_ 
the treatment of diseases upon the scientific basis 
of physiology. Every chapter, every line, has the 
impress of a master hand, and while the work is 
thoroughly scientific in every particular, it presents 



contains much concentrated worldly wisdom ; and, 
if carefully read, digested, and assimilated, will, in 
many an emergency, stand the young medical man 
in good stead.— Lond. Med. Record, Oct. 12, 1S80. 



F 



7NLAYSON {JAMES), M.D., 

Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc. 

CLINICAL DIAGNOSIS; A Handbook for Students and Prac- 

titioners of Medicine. In one handsome 12mo. volume, of 546 pages, with 85 illustra- 
tions. Cloth, $2 63. (hatelv Issued.) 

tive from preface to the final page, and ought to be 
given a place on every office table, because it contains 
inacondensedform all that is valuable in semeiology 
and diagnostics to be found in bulkier volumes, and 
because in its arrangement and complete index, it is 
unusually convenient for quick reference in any 
mergency that may come upon the busy practitioner. 



The book is an excellent one, clear, concise, conve- 
nient, practical. It is replete with the very know- 
ledge the student needs when he quits the lecture- 
room and the laboratory for the ward and sick-room, 
and does not lack in information that will meet the 
wants of experienced and older men. — Phila. Med. 
Times, Jan. 4, 1879. 

This is one of the really useful books. It is attrac- 



—N. C. Med. Journ., Jan. 1879. 



jyATSON (THOMAS), M.D., frc. 

LECTURES ON THE PRINCIPLES AND PRACTICE OF 

PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- 
vised and enlarged English edition. Edited, with additions, and several hundred illustra- 
tions, by Henry Hartshorne, M.D., Professor of Hygiene in the University of Penn- 
sylvania. In two large and handsome 8vo. vols. Cloth, $9 00 ; leather, $11 00. 



WILLIAMS'S PULMONARY CONSUMPTION; its 
Nature, Varieties and Treatment. With an An- 
alysis of One Thousand Cases to exemplify its 
duration. In one neat octavo volume of about 
350 pages ; cloth, $2 50. 

SLADE ON DIPHTHERIA; its Nature and Treat- 
ment, with an account of the History of its Pre- 
valence in various Countries Second and revised 
edition. In one neat royal 12mo. volume, cloth, 
$1 25. 



A r ALSHEON THE DISEASESOF THE HEART AND 
' GREAT VESSELS. Third American Edition. In 

1 vol. Svo., 420 pp., cloth, $3 00. 
SMITH ON CONSUMPTION ; ITS EARLY AND RE- 
MEDIABLE STAGES. 1 vol. Svo.. pp. 254 *2 25. 
FULLER ON DISEASES OF THE LUNGS AND AIR- 
PASSAGES. Their Pathology, Physical Diagnosis, 
Symptoms and Treatment. From the Second and 
revised English edition. In one hamlsome octavo 
volume of about 500 pages : cloth, $3 50. 



Henry C. Lea's Son & Co.'s Publications- — (Practice of Medicine). 17 
T?EYNOLI)S {J. RUSSELL), 31. D., 

J-V Prof, of the Principles and Practice of Medicine in Univ. College, London. 

A SYSTEM OF MWDT^TNE with Notes and !dd*tions by Hfnrt Hafts- 
horne, M.D., late Professor of Hygiene in the University of Penna. In three large and 
handsome octavo volumes, containing 3052 closely printed double-columned pages, with 
numerous illustrations. Sold only by subscription. Price per vol., in cloth, $r>.00 ; in 
sheep, $6.00 : half Russia, raised bands, $6.50. Per set in cloth, $15 ; sheep, $18 ; half 
Russia, $19.50 
Volume I. {just ready) contains General Diseases and "Diseases of the Nervous System. 
Volume II. {just ready) contains Diseases of Respiratory and Circulatory Systems. 
Volume III. (just ready) contains Diseases of the Digestive and Blood Glandular 
Systems, of the Urinary Organs, of the Female Reproductive System, and of the 
Cutaneous System. 
Reynolds's System of Medicine, recently completed, has acquired, since the first appearance 
of the first volume, the well deserved reputation of being the work in which modern British 
medicine is presented in its fullest and most practical form. This could scarce be otherwise in 
view of the fact that it is the result of the collaboration of the leading minds of the profession, 
each subject being treated by some gentleman who is regarded as its highest authority — as for 
instance, Diseases of the Bladder by Sir Henry Thompson, Malpositions of the Uterus by 
Graily Hewitt, Insanity by Henry Maudsley, Consumption by J. Hughes Bennet, Dis- 
eases of the Spine by Charges Bland Raocliffe, Pericarditis by Francis Sibson, Alcoholism 
by Francis E. Anstie, Renal Affections by William Roberts, Asthma by Hyde Salter, 
Cerebral Affections by H Charlton Bastian, Gout and Rheumatism by Alfred Baring Gar- 
rod, Constitutional Syphilis by Jonathan Hutchinson, Diseases of the Stomach by Wilson 
Fox, Diseases of the Skin by Balmanno Squire, Affections of the Larynx by Morell Mac- 
kenzie, Diseases of the Rectuin by Blizard Curling, Diabetes by Lauder Brunton, Intes- 
tinal Diseases by John Syer Bristowe, Catalepsy and Somnambulism by Thomas King Cham- 
bers, Apoplexy by J. Hughlings Jackson, Angina Pectoris by Professor Gairdner, Emphy- 
sema of the Lungs by Sir William Jenner, etc. etc. All the leading schools in Great Britain 
have contributed their best men in generous rivalry, to build up this monument of medical sci- 
ence. St. Bartholomew's, Guy's, St- Thomas's, University College, St. Mary's, in London, while 
the Edinburgh, Glasgow, and Manchester schools are equally well represented, the Army Medical 
School at Netley, the military and naval services, and the public health boards. That a work 
conceived in such a spirit, and carried out under such auspices should prove an indispensable 
treasury of facts and experience, suited to the daily wants of the practitioner, was inevitable, and 
the success which it has enjoyed in England, and the reputation which it has acquired on this 
side of the Atlantic, have sealed it with the approbation of the two pre-eminently practical nations. 
Its large size and high price having kept it beyond the reach of many practitioners in this 
country who desire to possess it, a demand has arisen for an edition at a price which shall ren- 
der it accessible to all. To meet this demand the present edition has been undertaken. The 
five volumes and five thousand pages of the original have, by tne use of a smaller type and double 
columns, been compressed into three volumes of over three thousand pages, clearly and hand- 
somely printed, and offered at a price which renders it one of the cheapest works ever presented 
to the American profession. 

But not only is the American edition more convenient and lower priced than the English; 
it is also better and more complete. Some years having elapsed since the appearance of a 
portion of the work, additions are required to bring up the subjects to the existing condition 
of science. Some diseases, also, which are comparatively unimportant in England, require more 
elaborate treatment to adapt the articles devoted to them to the wants of the American physi- 
orian ; and there are points on which the received practice in this country differs from that 
adopted abroad. The supplying of these deficiencies has been undertaken by Henry Harts- 
horne, M.D.,late Professor of Hygiene in the University of Pennsylvania, who has endeavored 
to render the work fully up to the day, and as useful to the American physician as it has proved 
to be to his English brethren. The number of illustrations has also been largely increased, and 
no effort spared to render the typographical execution unexceptionable in every respect. 

subjects with which he should be familiar. — Gail- 



Really too much praise can scarcely be given to 
this noble book. It is a cyclopaedia of medicine 
written by some of the best men of Europe. It is 
full of usefal information such as one finds frequent 
need of in oue's daily work As a book of reference 
it is invaluable. It is up with the times. It is clear 
and concentrated in style, and its form is worthy 
of its famous publisher. — Louisville Med. News, 
Jan. 31, 1SS0. 

"Reynolds' System of Medicine" is justly con- 
sidered the most popular work ou the principles and 
practice of medicine in the English language The 
contributors to this work are gentlemen of well- 
known reputation ou both sides of the Atlantic. 
Each gentleman has striven to make his part of the 
work as practical as pos-ible, and the information 
contained is such as is needed by the busy practi- 
tioner.— St. Louis Med. and Surg. Jo urn., Jan. '80. 

Dr. Hartshorne has made ample additions and 
revisions, all of which give increa^ed value to the 
volume, and render it more useful to the Ameri- 
ca u practitioner. There is no volume in English 
medical literature more valuable, and every pur- 
chaser will, on becoming familiar with it, congrat- 
ulate hilDRPlfnn the posspesior of this vast store- 
house of information, in regard to so many of the 



lard's Med. Journ., Feb. 1S80. 

There is no medical work which we have in times 
past more frequently and fully consulted when per- 
plexed by doubts as to treatment, or by having un- 
usual or apparently inexplicable symptoms pre- 
sented to us than "Reynolds' System of Medicine." 
Among its contributors are gentlemen who are as 
well known by reputation upon this side of the 
Atlantic as in Great BritaiD, and whose right to 
speak with authority upon the subjects about 
which they have written, is recognized the world 
ove»\ They have evidently striven to make their 
essays as practical as possible, and while these are 
sufficiently full to entitle them to the name of 
monographs, they are not loaded down with such 
an amount of detail as to render them wearisome 
to the general reader. In a word, they contain just 
that kind of information which the busy practitioner 
frequently finds himself in need of. "in order that 
any deficiencies may be supplied, the publishers 
have committed the preparation of the book for the 
press to Dr. Henry Hartshorne, whose judicious 
notesdistributed throughout the volume afford abun- 
dant evidence of the thoroughness of ihe revision to 
which he has subjected it. — Am. Jour.Mtd. Sciences, 
Jan. 1880. 



18 Henry C. Lea's Son & Co.'s Publications — (New. Dis , &c). 



T?ARTHOLOW {ROBERTS), A.M., M.D..LL.D. 

•*-* Prof, of Materia Medica. and General Therapeutics in the Jeff. Med. Coll. of Phila., etc. 

A PRACTICAL TREATISE ON ELECTRICITY IN ITS APPLI- 
CATION TO MEDICINE. In one very handsome 8vo. volume of about 270 pages, 
with 98 illustrations. Cloth, $2 50. {Just ready.) 

EXTRACT FROM THE AUTHOR'S PREFACE. 

I have attempted in the preparation of this work to avoid these errors; to prepare om so 
simple in statement that a student without previous acquaintance with the subject, may read- 
ily master the essentials; so complete as to embrace the whole subject of medical electricity, 
and so condensed as to be complete in a moderate compass. I have endeavored to keep con- 
stantly in view the needs of the two classes for whom the work is prepared — students and prac- 
titioners. I have as -'U med an entire unacquaintance with the elements of the subject as the 
point of departure — for I am addressing those who have either failed to acquire this prelimi- 
nary knowledge, or having acquired it, find that after the lapse of years, it has become m'sty 
and confused. In the accounts of electrcal phenomena I have adhered to the modes of expres- 
sion with which the medical electrical text-books have made us familiar. 

This book, then, must be regarded as the exposition of electricity as a remedial agent, made 
by a medic il practitioner for the use of medical practitioners. No claim is made on the ground 
of pure science. It is believed, however, that the work makes an adequate presentation of the 
subject, regarding electricity as a remedial agent — as one of the means employed for the treat- 
ment and cure of disease. 



So far as we know, the need of a clear, pimple, 
untechnical, reliable, concise, and modern treatise 
upon the subject of medical electricity is only sup- 
plied by the volume under consideration. It is not 
too much to say that, if availed of, it will render 
accessible to a vast number of members of the pro- 
fession a therapeutic agent of the greatest value, but 
which has heretofore been practically of no use 
whatever to them. — Maryland Med. Journal, June 
1, 1881. 

We have not yet come across a book that can com- 
pare with this in clearness and simplicity of state- 
ment. We have for a long time needed a text-book 
on medical electricity, condensed and yet complete, 
and this want has been well supplied by the distin- 
guished author. The illustrations are elegant, and 
the book as a whole is a valuable addition to the 
collection of any student or practitioner.— Bvffalo 
Med. and Surg. Journal, June, 1881. 

As a whole, the book must be looked upon as an 
exposition of electricity for remedial purposes, writ- 
ten by a medical practitioner for the use of medical 



practitioners. From this standpoint the work i3 
worthy of the careful study of all who desire to in- 
vestigate this subject for purely practical purposes. 
This work meets a want of very many students and 
medical practitioners. We greatly err if it be not 
gladly welcomed by them. The author, from his 
long experience as a practitioner, is admirably fitted 
to perform the task of writing a work of this kind 
for this special class of men. — Detroit Lancet, June, 
1881. 

This book is expressive of careful research and a 
nice discrimination in the selection of such matter 
from that at the author's command as is best adapted 
for the guidance and instruction of the physician 
whose interest in electricity is proportionate to its 
practical bearing on diagnosis and treatment. It is 
thorough, it is accurate, it is readable, and above 
all is essentially ufilizable, if we may use the word, 
and renders easy of access to the general practitioner 
the modus- operandi of employing this very valu- 
able therapeutic agent. — N. Y. Medical Gaz., June 
11, 1881. 



MITCHELL (S. WEIR), M.D., 

U.LL Phys. to Orthopozdic Hospital and the Infirmary for Bis. of the N'rvous System, Phila., etc etc. 

LECTURES ON DISEASES OF THE NERVOUS SYSTEM, 

ESPECIALLY IN WOMEN. In one very handsome 12mo. volume of about 250 pages, 

with five lithographic plates. Cloth, $1 75 (Just Ready) 
The life-long devotion of the author to the subjects discussed in this volume has rendered it 
eminently c'esirable that the results of his labors should be embodied for the benefit of those 
who may experience the difficulties connected with the treatment of this class of disease. 
Many of these lectures are fresh studies of hysterical affections; others treat of the modifica- 
tions his views have undergone in regard to certain forms of treatment, while, throughout the 
whole work, he has been careful to keep in view the practical lessons of his cases. 

It is a record of a number of very remarkable 
cases, with acute analyses and discussions, clinical, 
physiol* gical, and therapeutical It is a book to 
whifh the physician meeting wib a. new hysterical 
experience, or in doubt whether his new experience 
is hysterical, may well turn with a well-grounded 
hope of rinding a parallelism ; it will be a new ex- 
perience, indeed, if no similar one is here recorded 



—Phila. Med. Times, June 4, 1881. 

The name of the author is sufficient guarantee that 
these topics are ably and appreciate v. ly discussed ; 
suffice it to say that the principles of treatment, both 
hygienic and therapeutic, are clearly indicated. 
The articles being in the form of clinical lectures, 
abound in illustrative cases, and are much easier 
reading than a systematic treatise on the same 
topics. — College and Clinical Record, May 15, 1 81. 

It is needless to say that these lectures are extra- 



ordinarily rich in acute observation and sound in- 
struction. The reputation of the author is a guar- 
antee of that, and no rearer will be disappointed. 
Nor can too much be said in praise of the admirab e 
s' yle of his m' dical writings, and each of these lec- 
tures reads with the finished grace of a polished 
essay. Indeed, the book throughout is so fascinating 
a one that it could not fail to be read entire by every 
one who begins its pages. —Phila. Med. and Surg. 
Reporttr, May 7, 18S1. 

The book throughout is not only intensely enter- 
taining, but it contains a large amount of rare and 
valuable information. Dr Mi chell has recorded 
cot. f>nly the results of his most careful observation, 
but has added to the knowledge of the subjects treat- 
ed by his original investigation and practical study. 
The book is one we can commend to all of our read- 
ers — Maryland Med. Journal, May 1, 1SS1. 



JJAM1LTON {ALLAN M<LANE), M.D., 

"*■**- Attending Physician at the Hospital for Epileptics and Paralytics. BlackwelVs Island, N. Y., 

and at the Out- Patient s' Department of the New York Hospital. 

NERYOUSDISEASES;THEIR DESCRIPTION AND TREATMENT. 

Second edition, thoroughly revised and rewritten. In one handsome octavo volume of 
about 600 pages, with numerous illustrations. (In Press.) 



Henry C. Lea's Son & Co.'s Publications — (Dis.of the Skin, Sc). 19 
MORRIS [MALCOLM), M.D., 

J~*-L Joint Lecturer on Dermatology, St. Mary's Hospital Med. School. 

SKIN DISEASES, Including their Definitions, Symptoms, Diagnosis, 

Prognosis, Morbid Anatomy and Treatment. A Manual for Students and Practitioners. 
In one 12mo. volume of over 300 pages. With illustrations. Cloth, $1 75. (Now Ready .) 
To physicians who would like to know something 
about skin diseases, so that when a patient present*- 
himself for relief they can make a correct diagnosis 
and prescribea rational trea'ment, we unhesitatingly 
recommend this little book of Dr. Morris. The affec- 



tions of the skin are described in a terse, lucid man- 
ner, and their several characteristics so plainly set 
forth that diagnosis will be easy. The treatment 
in each case is such as the experience of the most 
eminent dermatologists advise. — Cincinnati Medi- 
cal News, April, 1SS0. 

This is emphatically a learner's book ; for we can 
safely say, so far as our judgment goes, that in the 
wh'">le range of medical literature of a like scope 

there is no book which for clearness of expression i subject of which it treats ; there is uo work published 
and methodical arrangement is better adapted to J which gives a better view of the elementary fact's 
promote a rational conception of dermatology, aland nrinciples of dermatology. — New Orleans Medi- 
branch confessedly difficult and perplexing to the ! cat and Surgical Journal, April, 1880. 



beginner. — St. Louis Courier of Medicine, April, 
1880. 

The author of this manual has evidently a full and 
intimate acquaintance with the literature of derma- 
tology, and with the most recent developments and 
appliances of cutaneous medicine. He has produced 
a plain, practical book, by aid of which, who so 
chooses may train his eye to the recoguiion of 
light but significant differences. The descriptions 
are neither too vaeue nor over-refined ; the direc- 
tions for treatment are clear and succinct. — London 
Brain, April, 1SS0. 

The author's task has been well done and has pro- 
duced one of the best recent works upon the difficult 



F 



'OX (T2LBDRD,M.D.,F.R.C.P..and T. C. FOX, B.A., M.R.C.S., 

Physician to the Department for Skin Diseases, University College Hospital. 

EPITOME OF SKIN DISEASES. WITH FORMULAE. For Stu- 

dents and Practitionkrs . Second edition, thoroughly revised and greatly enlarged. In 
one very handsome 12mo. volume of 216 pages. Cloth, $1 38. 

]?LINT [AUSTIN), M.D., 

■*• Professor of the Principles and Practice of Medicine in Bellevue Hospital Med. College, N. T. 

A MANUAL OF PERCUSSION AND AUSCULTATION; of the 

Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. 

Second edition. In one handsome royal 12mo. volume: cloth, $1 63. (Just Ready.) 

The little work before us has already become a I author has for m'ny jrear« given, in connection with 

standard one. and has become extensively adopted | practical instruction in auscultation and percussion, 

as a text-b^ok. There is certainly none better. It I to private classes, composed of medical students and 

contains the substance of the les-sons which the | p actitioners. — Cincinnati Med. News, Feb. 1SS0. 

DY THE SAME 'AUTHOR. 

PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, SYMPTOM- 
ATIC EVENTS AND COMPLICATIONS, FATALITY AND PROGNOSIS, TREAT 
MENT AND PHYSICAL DIAGNOSIS; in a series of Clinical Studies. By Austin 
Flint, M.D., Prof, of the Principles and Practice of Medicine in Bellevue Hospital Med. 
College, New York. In one handsome octavo volume : $3 50. 



T*Y THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, 

AND TREATMENT OF DISEASES OF THE HEART Second revised and enlarged 
edition. In one octavo volume of 550 pages, with a plate, cloth, $4. 

T> Y THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- 
TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE 
RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume 
of 595 pages, cloth, $4 50. 

RO WN [LENNOX), F.R.O.S. Ed., 

Senior Surgeon to the Central London Throat and Ear Hospital, etc. 

THE THROAT AND ITS DISEASES. Second American, from the 

Second English Edition, thoroughly revised. With one hundred Typical Illustrations in 
colors, and fifty wood engravings, designed and executed by the author. In one very 
handsome imperial octavo volume of over 350 pages. {Preparing. ) 

E1LER (CARL), M.D., 

Lecturer on Laryngoscopy at the Univ. of Penna., Chief of the Throat Dispensary at the 
Univ. Hospital, Phila., etc. 

HANDBOOK OF DIAGNOSIS AND TREATMENT OF DISEASES OF 

THE THROAT AND NAS\L CAVITIES. In one handsome royal 12mo. volume, 

of 156 pages, with 35 illustrations ; cloth, $1. (Lately Issued.) 

A convenient little handbook, clear, concise, and 
accurate in its method, and admirably fulfilling its 
purpose of bringing the subject of which it treats 
within the comprehension of the general practi- 
tioner.— N C. Med Jour., June, 1S79. 



B 



S 



We most heartily commend this book as showing 
sound judgment i n practice, and perfect familiarity 
with the literature of the specialty it so ably epi- 
tomizes.— Philada. Med. Times, July 5, 1S79. 



CLINTOAL OBSERVATIONS ON FUNCTIONAL 
NERVOUS DISORDERS Bv C. Handfield Jones. 
M.D.. Physician to St. Mary's Hospital, &c. Sec- 
ond America p Edition. In one handsome octavo 
volumeof 348 pages, cloth, $3 25. 



HILLIER'S HANDBOOK OF SKIN DISEASES, for 
Students and Practitioners. Second Am Ed. In 
one royal 12mo. vol. of 358 pp. "With illustrations. 
Cloth, $2 25. 



20 Henry C. Lea's Son & Co.'s Publications — (Venereal Diseases, &c). 



f>UMSTEAD {FREEMAN J.), M.D..LL.D., 

J~* Late Professor of Venereal Diseases at the Qol. of Phys. and Stirg., New York, &c. 

THE PATHOLOGY AND TREATMENT OF VENEREAL DIS- 

EASES. Including the results of recent (nvestigations upon the subject. Fourth Edition, 
revised and largely rewritten with the cooperation of R. W. Taylor, M.D., of New 
York, Prof, of Dermatology in the Univ. of Vt. En one large and handsome octavo 
volume of 835 pages, with 138 illustrations. Cloth, $4 75 ; leather, $5 75 j half Russia, 
$6 25. (Noio Ready.) 

"We have to congratulate our countrymen upon will more than renay him for the outlay. — Archives 
the truly valuable addition which they have made ; of Medicine, April, 1S Q 0. 

to American literature. The careful estimate of the j This now classical work on venereal disease comes 
value ot the volume, which we have made, justifies 



to us in its fourth edition rewritten, enlarged, aud 
materially improved in every way. Dr. Taylor, as 
we had every reason to exoect, has performed this 
part of his work with unusual excellence. We feel 
that what has been written has done but scanty jus- 
tice to the merits of this truly great treatise. — St. 



us iu declaring that this is the best treatise on 
venereal diseases in the English language, and we 
might add, if there is a better in any other tongue 
we cannot name it; there are certainly no books in 
which the student or the general practitioner can 

find such an excellent risumt of the literature of 'i'ouis Courts of Medi7ine*Ftf)*isS0 
any topic, and such practical suggestions regarding 
the treatment of the various complications of every 
venereal disease. We take pleasure in repeating 
that we believe this to be the best treatise on vene- 
real disease in the English language, and we con- 
gratulate the authors upon their brilliant addition 
to American medical literature. — Chicago Med. Jour- 
nal and Examiner, February, 18S0. 

It is, without exception, the most valuable single 
work on all branches of the subject of which it treats 
in any language. The pathology is sound, the work 
is, at the same time, iu the highest degree practical, 
and the hints that he will get from it for the man- 
agement of any one case, at all obscure or obstinate, 



We find that we have here practically a new book 
— that the statemeut of the title-page, as to the fact 
that it has been laraely rewritten, is a sufficiently 
modest announcement "for the important changes in 
the text. After a thorough examination of the pre- 
sent edition, we can assert confidently that the enor- 
mous labor we have described has been here most 
faithfully and conscientiously performed. — Araer 
Journ. Med. Sci., Jan. 1SS0. 

It is one of the best general treatises on venereal 
diseases with which we are acquainted, and is espe- 
cially to be recommended as a guide to the treatment 
of syphilis. — London Practitioner, March, 1SS0. 



f^ROSS {SAMUEL W.), A.M., M.D., 

t-* Lecturer on Genito-Urinary and Venereal Diseases in the Jefferson Medical College, Phila. 

A PRACTICAL TREATISE ON IMPOTENCE, STERILITY 

AND ALLIED DISORDERS OF THE MALE SEXUAL ORGANS. In one very hand 
some octavo volume of 174 pages, with 16 illustrations. Cloth, $1 50. (Jtist Ready.) 

EXTRACT FROM THS AUTHOR'S PREFACE. 

"My aim has been to supply, in a compact form, practical and strictly scientific information, 
especially adapted to the wants of the general practitioner, in regard to a class of common and 
grave disorders, upon the correction of which so much of human happiness depends. In the 
chapter on Sterility, the abnormal conditions of the semen and the causes which deprive it of 
its fecundating properties are fully considered — a portion of the work intended to supplement 
the subject of sterility in the female. From answers to letters addressed to many of the most 
prominent writers in this country on gynaecology, I find that, with few exceptions, the woman 
alone commands attention in unfruitful marriages. The importance of examining the husband 
before subjecting the wife to operation will be best appreciated when I state that he is, as a 
rule, at fault in at least one example in every six." 

ft UM STEAD {FREEMAN J.). 

•*-* Professor of Venerea I Diseases in the College of 
Physicians and Surgeons. N. T 

AN ATLAS OF VENEREAL DISEASES. Translated and Edited by 

FreejianJ. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns, 
with 26 plates, containing about 150 figures, beautifully colored, many of them the size of 
life; strongly bound in cloth, $17 00 ; also, in five parts, stout wrappers, at $3 per part. 
Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- 
lars a Part, thus placing it within the reach of all who are interested in this department of 
practice. G-entlemen desiring early impressions of the plates would do well to order it without 
delay. A specimen of the plates and text sent free by mail, on receipt of 25 cents. 



flULLERIER {A.), and 

*S Surgeon to the Hdpital du Midi. 



LEE'S LECTURES ON SYPHILIS AND SOME 
FORMS OF LOCAL DISEASE AFFECTING PRIN- 
CIPALLY THE ORGANS OF GENERATION. la 
one handsome octavo volume; cloth, $2 25. 

CONDIE'S PRACTICAL TREATISE ON THE DIS- 
EASES OF CHILDREN. Sixth edition, revised 
and augmented. In one large octavo volume of 
nearly Sf closely-printed pages, cloth, Jo 25 ; 
leather, $6 25. 

WILSON'S STUDENT'S BOOK OF CUTANEOUS 
MEDICINE and Diseases of the Skin. la one 
very handsome royal 12mo volume. $3 50. 

CHAMBERS'S MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. In one handsome 
octavo volume. Cloth, $2 75. 

B ASHAM ON RENAL DISEASES : a Clinical Guide 
to their Diagnosis and Treatment. With Illustra- 
tions. In one 12mo. vol. of 304 pages, cloth, $2 00. 



LECTURES ON THE STUDY OF FEYER. By A. 
Hudson, M.D., M.R.I. A., Physician to the Meath 
Hospital. In one vol. 8vo., cloth, $2 50. 

A TREATISE ON FEYER. By Robert D. Lyons, 
K.C.C. In one octavo volume of 362 pages, cloth 
*2 25. 

HILL ON SYPHILIS AND LOCAL CONTAGIOUS 
DISORDERS. In one handsome octavo volume; 
cloth $3 25. 

SMITH'S PRACTICAL TREATISE ON THE WAST- 
ING DISEASES OF INFANCY AND CHILDHOOD. 
Second American, from the Second revised and 
enlarged Enzlish edition. In one handsome octa- 
vo volume, cloth. $2 50. 

LA ROCHE ON PNEUMONIA. 1 vol.8vo., cloth, 
of 500 pages. Price, $3 00. 



Henry C. Lea's Son & Co.'s Publications — (Dis. of Children, &c). 21 
SMITH {J. LEWIS), M.I)., 

Clinical Professor of Diseases of Children in the Bellevue Hospital Med. College, N.Y. 

A COMPLETE PRACTICAL TREATISE OX THE DISEASES OF 

CHILDREN. Fifth Edition, thoroughly revised and rewritten. In one handsome oc- 
tavo volume of about 800 pages, with illustrations. {In Press.) 
The very marked favor with which this work has been received wherever the English lan- 
guage is spoken, has stimulated the author, in the preparation of the Fifth Edition, to spare 
no pains in the endeavor to render it worthy in every respect of a continuance of professional 
confidence. Many portions of the volume have been rewritten, and much new matter intro- 
duced, but by an earnest effort at condensation, the size of the work will not be materially 
increased. 

J£EATING (JOHNM.), M.D., 

Lecturer on the Diseases of Children at the University of Pennsylvania, etc. 

THE MOTHER'S GUIDE IN THE MANAGEMENT AND FEED- 
ING OF INFANTS. In one handsome 12mo. vol. of 118 pages. Cloth, $1 00. {Now 
Ready. ) 

In the preparation of thi3 volume, it has been the object of the author to provide a work that 
physicians can safely place in the hands of their patients for the purpose of instructing them 
as to the care and management of their children throughout the first three years of their life. 
While there already exist a nunaber of such manuals, there is yet lacking one of native ori- 
gin, especially adapted to the peculiarities of American climate, modes of living, and the vari- 
ous minor circumstances in which the customs of our country differ from those of the old world. 
The position occupied by the author as lecturer on Diseases of Children at the Univ. of Penna., 
is a guarantee of the satisfactory manner in which his labor has been performed. 

ffiEST (CHARLES), M.D., 

Physician to the Hospital for Sick Children, London, &c. 

LECTURES OX THE DISEASES OF IXFAXCY AXD CHILD- 

HOOD. Fifth American from the Sixth revised and enlarged English edition. In one large 
and handsome octavo volumeof 678 pages. Cloth, $4 50 ; leather, $5 50. 



gY THE SAME AUTHOR. { Lately Issued.) 

OX SOME DISORDERS OF THE XERYOUS SYSTEM IX CHILD- 
HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of 
London, in March, 1871. In one volume small 12mo., cloth, $1 00. 



flY THE SAVE AUTHOR. 

LECTURES OX THE DISEASES OF WOMEN. Third American, 

from the Third London edition. In one neat octavo volume of about 550 pages, cloth, 
$3 75; leather, $4 75. 



S 



WAYNE (JOSEPH GRIFFITHS), M.I)., 

Physician- Accoucheur to the British General Hospital, &c. 

OBSTETRIC APHORISMS FOR THE USE OF STUDEXTS COM- 
MENCING MIDWIFERY PRACTICE. Second American, from the Fifth and Revised 
London Edition, with Additions by E. R. Hutchi.ns, M.D. With Illustrations. In one 
neat 12mo. volume. Cloth, $1 25. 



CHURCHILL ON THE PUERPERAL FEVER AND MEIGS OX THE NATURE, SIGNS AND TREAT. 

OTHER DISEASES PECULIARTO WOMEN, lvol. MENT OF CHILDBED FEVER. 1 vol. Svo., pp. 

Svo., pp. 450, cloth. J 2 50. 365. cloth. - 

DEWEES'S TREATISE ON THE DISEASES OF FE- ASHWELL'S PRACTICAL TREATISE ON THE DIS- 

MALES. With illustrations. Eleventh Edition . j EASES PECULIAR TO WOMEN. Third American, 

with the Author's lastimprovementsand correc- j from the Third and revised Londonedition. 1 vol. 

tions. In one octavo volume of 536 pages, with i Svo., pp. 52S, cloth. $3 50. 

plates, cloth. $3 00. 



TX7IXCKEL (F), 

' * Professor arid Director of the Gynaecological Clinic in the University of Rostock. 

A COMPLETE TREATISE OX THE PATHOLOGY AND TREAT- 
MENT OF CHILDBED, for Students and Practitioners. Translated, with the consent 
of the author, from the Second German Edition, by James Read Chadwick, M.D. In 
one octavo volume. Cloth, $4 00. 



MONTGOMERY'S EXPOSITION OF THE SIGNS RIGBY'S SYSTEM OF MIDWIFERY. With notes 
AND SYMPTOMS OF PREGNANCY. With two j and Additional ^lustrations. Second Araeri( an 
exquisitecoloredplates. and numerons wood-cnts. j edition. One volume octavo, cloth, 422 p&ges, 
In lvol.Svo.,ofnearly600pp.,cloth,$3 75. I $2 50. 



22 Henry C. Lea's Son & Co.'s Publications — (Dis. of Women). 



r'HOMAS {T.GAILLARD),M.D., 
Professor of Obstetrics, &c in the College of Physicians and Surgeons, N. T., Ac 

A PRACTICAL TREATISEON THE DISEASES OFWOMEN. Fifth 

Edition, thoroughly revised and rewritten. In one large and handsome octavo volume 
of over 800 pages, with 266 illustrations. Cloth, $5 ; leather, $6 ; very handsome half 
Russia, raised bands, $6 50. (Just Ready.) 
The author has taken advantage of the opportunity afforded by the call for a new edition of 
this work to render it worthy a continuance of the very remarkable favor with which it has 
been received. Every portion of the work has been carefully revised, very much of it has 
been rewritten, and additions and alterations introduced wherever the advance of science and 
the increased experience of the author have shown them desirable. At the same time special 
care has been exercised to avoid undue increase in the size of the volume. To accommodate 
the numerous additions a more condensed but v> ry clear letter has been used, notwithstanding 
which, the number of pages has been increased by more than fifty. The series of illustrations 
has been extensively changed ; many which seemed to be superfluous have been omitted, and a 
large number of new and superior drawings have been inserted. In its improved form, there- 
fore, it is hoped that the volume will maintain the character it has acquired of a standard 
authority on every detail of its important subject. 

An examination of the work will satisfy that it is j its author's large experience, but reflects his care- 
one of great merit. It is not a mere compilation I ful study among other authorities in this hranch, 
from other -works, but is the fruit of the ripe | both at home and abr>ad Dr. Thomas is an able 
thought, sound judgment, and critical observations ■ and conscientious teacher. His wriings co»vey 
of a le>rned, scientific man. It is a treasury of ; his me-micg in the u arae practical and instructive 
knowledge of the department of medicine to which : manner. The last edition of this work is fresh from 
it is devoted In its present revised state it cer- hi-; pen, wiih decided changes and improvements 
tainly hold* a foivmost position as a gynaecological over former edi'ioos. His book presents generally 
work, and will continue to be regarded as a stau- accep ; ed facts, and as a guide 'o the student is more 
dard authority — Cincinnati Med. News, Dec. 18S0. , useful and reliable than any work in the language 

This work needs no introduction to any of the on diseases of women. This last edition will add 
civilized nations of the world. The edirion before j new laurels to those already won. — Md. Med. 
us adds to the strengh of former volumes. With Journ., Nov. 15, 1830. 

the wisdom of a master teacher he here gives the It has been enlarged and carefully revised. The 
results that, in his judgment, are most trustworthy i author has brought it fully abreast with the times, 
at the present time, in its own place it has no I and as the wave of gynaecological progression has 
rival, because the author is the best teacher on this j been widespread and rapid during the twelve years 
subject to the masses of the profession As hitherto ! that have elapsed since the issue of the first edition, 
this work will be the text-book on diseases of wo- ; one can conceive of the great improvement this edi- 
men. We only wish that in other branches of medi- j tion must be upon the earlier. It is a condeQsed en- 
cine as capable teachers could be found to write our cyclopaedia of gynaecological medkine. The style of 
text-books. — Detroit Lancet, Jan. 1SS1. arrangement, the mauerly manner in which each 

Since its first appearance, twelve vears ago, until sab Jfi is treated, and the honest convictions de- 
the prevent dav, it has held a position of high re- \ ri ^ d from P^^\7 the largest clinical experience 
gard, and is generally conceded to be one of the ! ln that specialty of any m this country, all serve to 
most practical and trustworthy volumes yer pre- j commend it in the highest terms to the practitioner, 
seated to the physician and student in the depart- -Nashmlle Journ. of Med. and Surg., Jan. 1881. 
ment of gynaecology. The woik embodies not only ' 



B 



JfiDIS [ARTHUR W.), M.D., Lond. F.R.C.R, M.R.C.S. 

Assist. Obstetric Physician to Middlesex Hospital, late Physician to British Lying-in Hospital. 

THE DISEASES OF WOMEN. Including their Pathology, Causa- 

tion, Symptoms, Diagnosis, and Treatment. A manual for Students and Practitioners. 
In one handsome volume with numerous illustrations. (Shortly.) 

ARNES [ROBERT), M.D., F.R.C.P., 

Obstetric Physician to St. Thomas' s Hospital, A-c. 

A CLINICAL EXPOSITION OF THE MEDICAL AND SURGI- 
CAL DISEASES OF WOMEN. Second American, from the Second Enlarged and Revised 
English Edition. In one handsome octavo volume, of 784 pages, with 181 illustrations. 
Cloth, $4 50; leather, $5 50; half Russia, $6. (Lately Issued.) 

Dr. Barnes stands at the head of his profession in , plexity of the man of mature years. — Canadian 
the old country, and it requires but scant scrutiny i Journ. of Med. Science, Nov. 1878. 
of his book to show that it has been sketched by a : Dr . Barnes's work is one of a practical character, 
master. It is plain, practical common sense; shows j largely illustrated from cases in hisowu experience, 
very deep research without being pedantic ; is emi- : but b Q0 means C onf ned to such, as will be learned 
nently calculated to inspire enthusiasm without in- j from the fact that be quotes f rom no less than 628 
culcating rashuess; points out the dangers to be medical authors in numerous countries. Coming 
avoidpd as well as the success to be achieved in the r rnro Bucb an author, it is not necessarv to say that 
various operations connected with this branch of the work is a valuable one, and should be largely 
medicine: and will do much to smooth the rugged con . ulte(i bv the profession.— Am. Svpp Obstetrical 
path of the young gynaecologist and relieve the per- | Journ _ GL Britain and Ireland, Oct. 1S78. 



H 



ODGE [HUGH L.), M.D., 

Emeritus Professor of Obstetrics, &c, in the University of Pennsylvania. 

ON DISEASES PECULIAR TO WOMEN; including Displacements 

of the Uterus. With original illustrations. Second edition, revised and enlarged. In 
one beautifully printed octavo volume of 531 pages, cloth, $4 50. 



E 



Henry C. Lea's Son & Co.'s Publications — (Dis. of Women). 23 
'MMET {THOMAS ADDIS). M.D., 

Surgeon to the Woman's Hospital, New York, etc, 

THE PRINCIPLES AND PRACTICE OF GYNAECOLOGY, for the 

use of Students and Practitioners of Medicine. Second Edition. Thorougly Revised. 
In one large and very handsome octavo volume of 875 pages, with 133 illustrations. 
Cloth, $6; leather, $6 ; half Russia, raised bands, $6 50. {Just Ready.) 



Preface to the Second Edition. 
The unusually rapid exhaustion of a large edition of this work, while flattering to the author 
as an evidence that his labors have proved acceptable, has in a great measure heightened his 
sense of responsibility. He has therefore endeavored to take full advantage of the opportunity 
afforded to him for its revision. Every page has received his earnest scrutiny; the criticisms 
of his reviewers have been carefully weighed ; and while no marked increase has been made in 
the size of the volume, several portions have been rewritten, and much new matter has been 
added. In this minute and thorough revision, the labor involved has been much greater than 
is perhaps apparent in the results, but it has been cheerfully expended in the hope of rendering 
the work more worthy of the favor which has been accorded to it by the profession. 



In no country of the world bas gynaecology re- 
ceived more attention than in America. It is, then, 
with a feeling of pleasure that we welcome a work 
on diseases of women from so eminent a gyuseeolo 
gist as Dr. Emmet, and the work is essentially clini- 
cal, and leaves a strong impress of the author's in- 
dividuality. To criticize, with the care it merits, 
the book throughout, would demand far more spac* 
than is at our command. In parting, we can say 
that the work teems with original ideas, fresh and 
valuable methods of practice, and is written in a 
clear and elegant style, worthy of the literary repu- 
tation of the country of Longfellow and Oliver Wen- 
dell Holmes.— Brit. Med. Journ. Feb. 21, 18S0. 

No gynaecological treatise has appeared which 
contains an equal amount of original and useful 
matter; nor does the medical and snrgical history 
of America include a book more .novel and useful. 
The tabular and statistical information which it 
contains is marvellous, both in quantity and accu- 
racy, and cannot be otherwise than invaluable to 
future investigators. It is a work which demands 



not careless reading but profound study. Its value 
as a contribution o gyusecology is, perhaps, greater 
than that of all previous lirerature on the subject 
combined.— Chicago Med Gaz., April 5, 1SS0 

The wide reputation of the author makes its pub- 
lication an event in the gynaecological world ; and 
a glance through its pages shows that it is a work 
to be studied with care. ... It must always be a 
work to be carefully studied and frequently con- 
sulted by those who practise this branch of our pro- 
fession. — Lond. Med. Times'and Gaz.., Jan. 10, 18S0. 

The character of the work is too well known to 
require extended notice — suffice it to say that no 
recent work upon any subject has attained such 
great popularity .-o rapidly. As a work of general 
reference upon the subject of Diseases of Women it 
is invalaable. As a record of the largest clinical 
experience and observation it has no equal. No 
physician who pretends to keep up with the ad- 
vances of this department of medicine can afford to 
be without it. — Nashville Journ. of Medicine and 
Surgery, May, IPSO. 



D 



UNCAN {J. MATTHEWS), M.D., LL.D., F.R.S.E., etc. 

CLINICAL LECTURES ON THE DISEASES OF WOMEN, 

Delivered in Saint Bartholomew's Hospital. In one very neat octavo volume of 173 

pages. Cloth, $1 50. (Just Ready.) 

The author is a remarkably clear lecturer, and 
his discussion of symptoms and treatment is full 
and suggestive. It will be a work which will not 
fail to be read with benefit by practitioners as well 
as by students. — Phila. Med. and Surg. Reporter, 
Feb. 7, 1S80. 

We have read this book with a great deal of 
pleasure. It is fall of good things. The hints on 
pathology and treai ment scattered through the book 
are sound, trustworthy, and of great value. A 
healthy scepticism, a large expeiience, and a clear 
judgment are everywhere manifest. Instead of 
bristling with advice of doubtful value and un- 
sound character, the book is in every respect a safe 
guide. — The London Lancet, Jan. jfl, 1S&0. 



They are in every way worthy of their author ; 
indeed, we look upon them asamoug the most valu- 
able of his contributions They are all up >n mat- 
ters of great interest to the general practitioner. 
Some of tlu'in deal with subjects that are not, as a 
rule, adequately handled in the text-books ; others 
of them, while bearing upon topics that are usually 
treated of at length in such works, yet bear such a 
stamp of individuality that, if widely read, as they 
certainly deserve to be, they cannot fail to exert a 
wholesome restraint upon the undue eagerness with 
which many young physicians seem bent upon fol- 
lowing the wild teachings which so infest the gyuse- 
cology of the present day. — N. T. Med. Journ., 
March, 1880. 



L>AMSBOTHAM [FRANCIS H), M.D. 

THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- 

CINE AND SURGERY, in reference to the Process of Parturition. A new"* and enlarged 
edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., 
Professor of Obstetrics, &c, in the Jefferson Medical College, Philadelphia. In one larsre 
and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised 
bands ; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in 
all nearly 200 large and beautiful figures. $7 00 

J>ARRY [JOHN S.), M.D., 

Obstetrician to the Philadelphia Hospital, Vice-Prest. of the Ohstet. Society of Philadelphia. 

EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, 

DIAGNOSIS, PROGNOSIS AND TREATMENT. In one handsome octavo volume. 
Cloth, $2 50. 

WANNER {THOMAS H.), M.D. 

ON THE SIGNS AND DISEASES OF PREGNANCY. First American 

from the Second and Enlarged English Edition. With four colored plates and illustra- 
tions on wood. In one handsome octavo volume of about 500 pages, oloth, $4 25. 



24 Henry C. Lea's Son & Co.'s Publications— {Midwifery). 



EISHMAN ( WILLIAM), M.D., 

Regius Professor of Midwifery in the University of Glasgow, Ac. 

A SYSTEM OF MIDWIFERY, INCLUDING THE DISEASES OF 

PREGNANCY AND THE PUERPERAL STATE. Third American edition, revised by 
the Author, with additions by John S. Parry, M.D., Obstetrician to the Philadelphia 
Hospital, Ac. In one large and very handsome octavo volume, of 733 pages, with over 
two hundred illustrations. Cloth, $4 50 ; leather, $5 50 ; half Russia, $6. {Just Ready ) 

seems to require, and we cannot but admire the 
ability with which the task has been performed. 
We consider it an admirable text-book for students 
during their attendance upon lectures, and have 
great pleasure in recommending it. As an exponent 
of the midwifery of the present day it has no supe- 
rior in the English language. — Canada Lancet, Jan. 
1S80. 



Few works on this subject have met with as great 
a demand as this one appears to have. To judge 
by the frequency with which its author's views are 
quoted, and its statements referred to in obstetrical 
literature, one would judge that there are few phy- 
sicians devoting rnach attention to obstetrics who 
are without it. The author is evidently a man of 
ripe experience and conservative views, and in no 
branch of medicine are these more valuable than in 
this. — New Remedies, Jan. 1880. 

We gladly welcome the new edition of this excel- 
lent text-book of midwifery. The former editions 
have been most favorably received by the profes- 
sion on both sides of the Atlantic. In the prepara- 
tion of the present edition the author has made such 
alterations as the progress of obstetrical science 



To the American student the work before us must 
prove admirably adapted, complete in all its parts, 
essentially modern in its teachings and with dem- 
onstrations noted for clearness and precision, it will 
gain in favor and be recognized as a work of stand- 
ard merit. The work cannot fail to be popular, and 
is cordially recommended.— N. 0. Med. and Sicrg. 
Journ., March, 1880. 



pLAYFAIR ( W. S.), M.D., F.R.G.P., 

~^~ Professor of Obstetric Medicine in King's College, etc. etc. 

A TREATISE ON THE SCIENCE AND PRACTICE OF MIDWIFERY. 

Third American edition, revised by the author. Edited, with additions, by Robert P. 
Harris, M.D. In one handsome octavo volume of about 700 pages, with nearly 200 
illustrations. Cloth, $4 ; leather, $5 ; half Russia, $5 50. {Just Ready.) 

The medical profession has now the opportunity 
of adding to their stock of standard medical works 
one of the best volumes on midwifery ever published. 
The subject is taken up with a master hand. The 



part devoted to laborin all its various presentations, 
the management and results, is admirably arranged, 
and the views entertained will be found essentially 
modern, and the opinions expressed trustworthy. 
The work abounds with plates, illustrating various 
obstetrical positions; they are admirably wrought, 
and afford great assistance to the student. — N. O. 
Med. and Surg. Journ., March, 1880. 

If inquired of by a medical student what work on 
obstetrjes we should recommend for him, as par 
excellence, we would undoubtedly advise him to 
choose Piayfair's. It is of convenient size, but what 
is of chief importance, its treatment of the various 
subjects is concise and plain. While the discussions 
and descriptions are sufficiently elaborate to render 



a very intelligent idea of them, yet all details not 
necessary for i full understanding of the subject are 
omitted.— Cincinnati Med. News, Jan. 1880. 

The rapidity with which one edition of this work 
follows another is proof alike of its excellence and 
of the estimate that the profession has formed of it. 
It is indeed so well known and so highly valued 
that nothing need be said of it as a whole. All 
things considered, we regard this treatise as the very 
best on Midwifery in the English language.— ^. Y. 
MedicalJournal, May, 1880 

It certainly is an admirable exposition of the 
Science and Practice of Midwifery. Of course the 
additions made by the American editor, Dr. E. P. 
Harris, who never utters an idle word, and whose 
studious researches in some special departments of 
obstetrics are so well known to the profession, are 
of great value.— The American Practitioner, April, 
1880. 



J?ARNES {FANCOURT), M.D., 

•*-* Physician to the General Lying-in Hospital, London. 

A MANUAL OF MIDWIFERY FOR MIDWIYES AND MEDICAL 

STUDENTS. With 50 illustrations. In one neat royal 12mo. volume of 200 pages ; 
cloth, $1 25. {Now Ready.) 



JpARVIN {THEOPHILm), M.D., 

Prof, of Obstetrics and of the Med. and Surg. Diseases of Women in the Med. Coll. of Indiana. 

A TREATISE ON MIDWIFERY. In one very handsome octavo 

volume of about 550 pages, with numerous illustrations. {Preparing.) 



H 



ODGE {HUGH L.), M.D., 

Emeritus Professor of Midwifery, Ac, in the University of Pennsylvania, Ac. 

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- 

trated with large lithographic plates containing one hundred and fifty-nine figures from 
original photographs, and with numerous wood-cuts. In one large and beautifully printed 
quarto volume of 550 double-columned pages, strongly bound in cloth, $14. 



The work of Dr. Hodge is something more than 
a simple presentation of his particular views in the 
department of Obstetrics; it is something more 
than an ->rdinarytreatise on midwifery; it is, in fact, 
a cyclopaedia of midwifery. He has aimed to em- 



body in a 3ingle volume the whole science and art of 
Obstetrics. An elaborate text is combined with ac- 
curate and varied pictorial illustrations, so that no 
fact or principle Is left unstated or unexplained. 
—Am. Med. Times, Sept. 3, 1864. 



^*^ Specimens of the plates and letter-press will be forwarded to any address, free by mail, 
on receipt of six cents in postage stamps. 



ffHAD WICK (JAMES R. 

A MANUAL OF THE DISEASES PECULIAR TO WOMEN. 



A.M., M.D. 

[SEASES I 
aeafc volume, royal 12mo., with illustrations. {Preparing.} 



In one 



Henry C. Lea's Son & Co.'s Publications— {Surgery). 



25 



TJAMILTON {FRANK H.) M.D., LL.D., 

-*--*- Surgeon to the Bellevue Hospital, New York. 

A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- 
TIONS Sixth Edition, thoroughly revised, and much improved. In one very handsome 
octavo volume of over 900 pages, with 352 illustrations. Cloth, $5 50; leather, $6 50; 
half Russia, raised bands, $7 00. (Just Ready.) 

Dr Hamilton has devoted great labor to thestudy 
of these subjects. His large experience, extended 
research, and patien r investigation have made him 
one of the highest authorities among living writers 
in this branch of surgery This work is systematic 
and practical in its arrangement, and presents its 
subject matter clearly and forcibly to the reader 
or student. — Maryland Medical Journal, Nov. 15, 
1880. 

The only complete work on its subject in the Eos* 
lish tongue, and, indeed, may now be said to be 
the only work of iis kind in any tongue. It would 
require an exceedingly critical examination to de- 
tect iju it any particulars in which t might be im- 
proved. The work is a monument to American 
surgery, and will long serve to ke>p green the 
memory of its venerable author.— Michigan Med 
News, Nov. 10, 1S51. 



So many kind expressions of welcome have been 
showered upon each successive ediiion of this val- 
uable treatise, that scarcely anything leruains for 
us to do but to extend the customary cordial greet- 
ing. It is the only complete work on the subject 
of Fractures in the English language. We con- 
gratulate the accomplished author on the deserved 
success of his work, and hope that he may live to 
have many .succeeding editions pass under his skil 1- 
ed supervision. — Phila. Coll. and Clin. Record, 
Nov. 15, 1S80. / 

Universal verdict has pronounced it, humanly 
speaking, a perfect treat ^e upon this subject. As 
it is the only compiet and illustrated work in any 
language treating of fractures and dislocations, it 
is safe to affirm that every wide-awake surgeon and 
general practitioner will regard it as indispensable 
to the safe and pleasaDt conduct of their profes- 
sional work. — Detroit Lancet, Nov. IS, 1SS0. 



A SHHURST {JOHN, Jr.), M.D. 






Prof, of Clinical Surgery, Univ. of Pa., Surgeon to the Episcopal Hospital, Philadelphia. 

THE PRINCIPLES AND PRACTICE OP SURGERY. Second 

Edition, enlarged and revised. In one very large and handsome octavo volume of over 
1000 pages, with 542 illustrations. Cloth, $6; leather, $7; half Russia, $7 50. {Just 
Is sited.) 

language all that is necessary to be learned by the 
student of surgery whilst in attendance upon lec- 
tures, or the general practitioner in his daily routine 
practice.— Md. Med. Journal, Jan. 1S79. 



Conscientiousness and thoroughness are two very 
marked traits of character in the author of this 
book. Out of these traits largely has grown the 
success of his mental fruit in the past, and the pre- 
sent offer seems in no wise an exception to what has 
gone before. The general arrangement of the vol- 
ume is the same as in the first edition, but every part 
has been carefully revised, and much new matter 
added.— Phila. Med. Times, Feb. 1, 1S79. 

The favorable reception of the first edition is a 
guarantee of the popularity of this edition, which is 
fresh from the editor's hands with many enlarge- 
ments and improvements. The author of this work 
is deservedly popular as an editor and writer, and 
his contributions to the literature of surgery have 
gained for him wide reputation. The volume now 
offered the profession will add new laurels to those 
already won by previous contributions. We can 
only add that the work is well arrange d, filled with 
practical matter, and contains in brief and clear 



The fact that this work has reached a second edi- 
tion so very soon after the publication of the first 
one, speaks more highly of its merits than anything 
we might say in the way of commendation, it 
seems to have immediately gained the favor of stu- 
dents and physicians. — Cinein. Med. News, Jan. '79. 

We have previously spoken of Dr. Askhurst's 
work in terms of praise. We wish to reiterate those 
terms here, and to add that no more satisfactory 
representation of modern surgery has yet fallen 
from the press. In point of judicial fairness, of 
power of condensation,-of accuracy and conciseness 
of expression anl thoroughly good English, Prof. 
Ashhurst has no superior a mong the surgical writers 
in America. — Am. Practitioner, Jan. 1879. 



QTIMSON {LEWIS A.), A.M., M.D., 

*3 Surgeon to the Presbyterian Hospital. 

A MANUAL OF OPERATIVE 

royal 12mo. volume of about 500 pages, i 

The work before us is a well printed, profusely 
illustrated manual of over four hundred and seventy 
pages. The novice, by a perusal of the work, will 
gain a good idea of the general domain of operative 
surgery, while the practical surgeon has presented 
to him within a very concise and intelligible form 
the latest and most approved selections of operative 
procedure. Theprecision and conciseness with which 
the different operations are described enable the 
author to compress an immense amount of practical 
information in a very small compass. — N. ¥. Medical 
Record, Aug. 3, 187S. 

This volume is devoted entirely to operative sur- 
gery, and is intended to familiarize the student with 
thedetails of operations and the different modes of 



SURGERY. In one very handsome 

vith 332 illustrations ; cloth, $2 50. 
performing them. The work is handsomely illus- 
trated, and the de> criptious are clear and well drawn. 
It is a clever and useful volume ; every student 
should possess one. The preparation of this work 
does away with the necessity of pondering over 
larger works on surgery for descriptions of opera- 
tions, asit presents in a nut-shell just whatis wanted 
by the surgeon without an elaborate search to find 
it. — Md. Med Journal, Aug. 1S78. 

The author's conciseness and the repleteness of 
the work with valuable illustrations entitle it to be 
classed with the text-books for students of operative 
surgery, and as one of reference to the practitioner. 
— Cincinnati Lancet and Clinic, July 27, 1S78. 



SKEY'S OPERATIVE SURGERY. In 1 vol. 8vo. 
el., of650 pages ; withabout lOOwood-cuts. $3 25. 

COOPER'S LECTURES ON THE PRINCIPLES AND 
Practice of Surgery. Inl vol. 8vo.cl'h,750p. $2. 

GIBSON'S INSTITUTES AND PRACTICE OF SUR- 
GERY. Eighth edit'n, improved and altered. With 
thirty-four plates. In two handsome octavo vol- 
umes, about 1000 pp., leather, raised bandF. $6 50. 

THE PRINCIPLES AND PRACTICE OF SURGERY. 
By William Pirrie,F.R S.E., Profes'rof Surgery 
in the Universityof Aberdeen. Edited by John 



Netll, M.D., Professorof Surgery in the Penna. 
MedicalCollege.Surg'n to the Pennsylvania Hos- 
pital, &c. In one very handsome octavo vol. of 
780 pages, with 316 illustrations, cloth, $3 75. 

MILLER'S PRINCIPLES OF SURGERY. Fourth Ame- 
rican, from the Third Edinburgh Edition. In one 
large 8vo. vol. of 700 pages, with 340 illustrations 
cloth, $3 75. 

MILLER'S PRACTICE OF SURGERY. Fourth Ame- 
riesu, from the last Edinburgh Edition Revised by 
the American editor. In onelarge 8vo. vol. of nearly 
TOO pages, with 364 illustrations: cloth, $3 75. 



26 



Henry C. Lea's Son & Co.'s Publications — (Surgery). 



yROSS {SAMUEL />.), M.D., 

" Professor of Surgery in the Jefferson Medica I College of Philadelphia . 

A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic 

and Operative. Illustrated by upwards of Fourteen Hundred Engravings. Fifth edition, 
carefully revised and improved. In two large and beautifully printed imperial octavo vol- 
umes of about 2300 pp., strongly bound in leather, with raised bands, $15 ; half Russia, 
raised bands, $16. 



We have seldom read a work with the practical 
value of which we have been more impressed. Every 
chapter is so concisely put together, that the busy 
practitioner, when in difficulty, can at once find the 
information he requires. His work is cosmopolitan, 
the surgery of the world being fully represented in it. 
The work, in fact, is so historically unprejudiced, and 
so eminently practical, that it is almost a false compli- 
ment to say thatwe believe it to be destined to occupy 
a foremost place as a work of reference, while a system 
of surgery like the present system of surgery is the 
practice of surgeons. The printingand binding of the 
work is unexceptionable; indeed, it contrasts, in the 
latter respect, remarkably with English medical and 
surgical cloth-bound publications, which are generally 
so wretchedly stitched as to require re- binding before 
they are anytime in use. — Dub. Journ. of Med. Sci.. 
March, 1874. 

Dr. Gross's Surgery, a great work, has become stilJ 
greater, both in size and merit, in its mostrecentform. 
The difference in actual number of pages is not more 
than 130, but. the size of the page having been in- 
creased to what we believe is technically termed "ele- 
phant, "there has been roomforconsiderableadditions, 
which, together with the alterations, are improve- 
ments. — Lond. Lancet, Nov. 16,1872. 

It combines, as perfectly as possible, the qualities of 
a text-book and work of reference. We think this last 
edition of Gross's "Surgery," will confirm his title of 



' Primus inter Pares." It is learned, scholar-like, me- 
thodical, precise, and exhaustive. We scarcely think 
any living man could write so complete and faultless a 
treatise, or comprehend more solid, instructive matter 
in the given number of pages. The labor must have 
been immense, and the work gives evidence of great 
powers ofmind.and the highest order of intellectual 
discipline and methodical disposition and arrangement 
of acquired knowledge and personal experience. — N.Y. 
Med. Journ., Feb. 181 Z. 

As a whole, we regard the work as the representative 
"System of Surgery" in the English language. — St. 
Louis Medical and Surg. Journ., Oct. 1872, 

The two magnificent volumes before us afford a very 
complete view of the surgical knowledge of the day. 
Some years ago we had the pleasure of presenting the 
first edition of Gross's Surgery to the profession as a 
work of unrivalled excellence; and now we have the 
result of years of experience, labor, and study, all con- 
densed upon the great work before us. And to students 
or practitioners desirous of enriching their library with 
a treasure of reference, we can simply commend the 
purchase of these two volumes of immense research — 
Cincinnati Lancet and Observer, Sept. 1872. 

A complete system of surgery — not a mere text-book 
of operations, but a scientific account of surgical theory 
and practicein all its departments. — Brit, and For. 
Med. Chir. Rev., Jan. 1873. 



T>Y THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE DISEASES, INJURIES 

and Malformations of the Urinary Bladder, the Prostate Gland and the Urethra. Third 
Edition, thoroughly Revised and Condensed, by Samuel W. Gross, M.D., Surgeon to 
the Philadelphia Hospital. In one handsome octavo volume of 574 pages, with 170 illus- 
trations: cloth, $4 50. 



For reference andgeneral information, the physician 
or surgeon can find no work that meets their necessities 
more thoroughly than this, a revised edition of an ex- 
cellent treatise, and no medical library should be with- 
out it. Replete with handsome illustrations and good 
ideas, it has the unusual advantage of being easily 
comprehended, by the reasonableand practical manner 
in which the various subjects are systematized and 
arranged We heartily recommendit to the profession 
as a valuable addition to the important literature of dis- 



eases of the urinary organs. — Atlanta Med .Journ.,Oct. 
1876. 

It is with pleasure we now again take up this old 
work in a decidedly new dress. Indeed, it must be re- 
garded as a new book in very many of its parts. The 
chapters on "Diseases of the Bladder," "Prostate 
Body," and "Lithotomy," are splendid specimens of 
descriptive writing; while the chapter on "Stricture" 
is one of the most concise and clear that we have ever 
read. — New York Med. Journ., Nov. 187 6. 



T>Y THE SAME AUTHOR. 

A PRACTICAL TREATISE ON FOREIGN BODIES IN THE 

AIR-PASSAGES. In 1 vol. 8vo., with illustrations, pp. 468, cloth, $2 75. 



(10LEMAN [ALFRED), L.R.C.R, F.R.C.S., L.B.S., etc. 

Senior Dental Surgeon and Lecturer on Dental Surgery to St. Bartholomew' s Hospital and the 
Dental College of London. 

A MANUAL OF DENTAL SURGERY AND PATHOLOGY. 

Thoroughly revised and adapted to the use of American students, by Thomas C. Stell- 
wagen, M.A., D.D.S., Professor of Physiology at the Philadelphia Dental College. In 
one handsome volume with about 400 illustrations. {In Press.) 

T)RUITT {ROBERT), M.R.G.S., frc. 

THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. 

A new and revised American, from the Eighth enlarged and improved London edition. Illus- 
trated with four hundred and thirty -two wood engravings. In one very handsome octavo 
volume, of nearly 700 large and closely printed pages, cloth, $4 00 ; leather, $5 00. 



InMr.Druitt'sbook, though containing only some 
seven hundred pages, both the principles and the 
practice of surgery are treated, ana so clearly and 
perspicuously, as to elucidate every important topic. 
We have examined thebook most thoroughly, anc 



cansay that thissuccessis well merited. His book, 
moreover, possesses the inestimable advantages of 
having the subjects perfectly well arranged and 
classified and of being written in a style at once 
clear ind snecinct. — Am. Journal of Med. Sciences 



ASHTON ON THE DISEASES, INJURIES, and MAL- 
FORMATIONS OF THE RECTUM AND ANUS: 
with remarks on Habitual Constipation. Second 
American, from the Fourth and enlarged London 
Edition. With illustrations. In one 8vo. vol. of 
287 pages, cloth, $3 25. 



SARGENT ON BANDAGING AND OTHER OPERA- 
TIONS OF MINOR SURGERY. New edition, with 
an additional chapter on Military Surgery. One 
12mo. vol. of 383pag9s withl8± wood-cuts Cloth, 
#175. 



Henry C. Lea's Son & Co.'s Publications — (Surgery). 



27 



H 



OLMES {TIMOTHY), M.A., 

Surgeon and Lecturer on Surgery at St. George' 



Hospital, London. 



A SYSTEM OF SURGERY; THEORETICAL AND PRACTICAL. 

In Treatises by various authors. American Edition, Thoroughly revised and 
rewritten by John H Packard, M.D., Surgeon to the Episcopal and St. Joseph's Hospi- 
tals, Philadelphia, assisted by a large corps of the most eminent American surgeons. In 
three large and very handsome imperial octavo volumes of about 1000 pages each, with over 
1000 illustrations on wood and thirteen lithographic plates, beautifully colored. (Sold 
only by subscription.) Price per volume, in cloth, 86 00; in leather, $7 00 ; in half 
Russia, $7 50. Per set, in cloth, $18 00 ; in leather, $21 00 ; in half Russia, $22 50. 
Volume I. (now ready) contains General Pathology, Morbid Processes, Injuries in 

General, Complications of Injuries and Injuries op Regions. 
Volume II. (nearly ready) contains Diseases of Organs of Special Sense, Circulatory 

System, Digestive Tract and Genito-urinary Organs. 
Volume III. (shortly) contains Diseases of the Respiratory Organs, Joints, Bones, and 
Muscles, Operative and Minor Surgery, Gunshot Wounds, Hospitals and Miscel- 
laneous Subjects. 
This great work, issued some years since in England, has won such universal confidence 
wherever the language is spoken, that its republication here, in a form more thoroughly 
adapted to the wants of the American practitioner, has seemed to be a duty owing to the pro- 
fession. 

To accomplish this, the aid has been invited of thirty-three of the most distinguished gentle- 
men, in every part of the country, and tor more than a year they have been assiduously engaged 
upon the task. Though the original work presents the combined labor of the most eminent 
members of all the most prominent schools of England, yet the lapse of time since the appear- 
ance of the last edition, the progress of science, and the peculiarities of American practice, 
have rendered necessary a most careful, thorough, and searching revision. Each article has 
been placed in the hands of a gentleman specially competent to treat its subject, and no labor 
has been spared to bring each one up to the foremost level of the times, and to adapt it thor 
oughly to the practice of the country. In certain cases, this has rendered necessary the sub- 
stitution of an entirely new essay for the original, as in the case of the articles on Skin Diseases, 
and on Diseases of the Absorbent System, where the views of the authors have been superseded 
by the advance of medical science, and new articles have therefore been prepared by Drs. Arthur 
Van Harlingen and S. 0. Busey, respectively. So also in the case of Anaesthetics, in the use 
of which American practice differs from that of England, the original has been supplemented 
with a new essay by J. C. Reeve, M.D., treating not only of the employment of ether and 
chloroform, but of the other anaesthetic .agents of more recent discovery. The same careful 
and conscientious revision has been pursued throughout, leading to an increase of nearly one- 
fourth in matter, while the series of illustrations has been more than doubled, and the whole 
is presented as a complete exponent of British and American Surgery, adapted to the daily 
needs of the working practitioner 

In order to bring it within the reach of every member of the profession, the five volumes of 
the original have been compressed into three, by employing a double-columned imperial octavo 
page, and in this improved form it is offered at less than one half the price of the original. It 
is beautifully printed on handsome laid paper and forms a worthy companion to Reynolds's 
" System of Medicine," which has met with so much favor in every section of the country. 

The work will be sold by subscription only, and in due time every member of the profession 
will be called upon and offered an opportunity to subscribe. 

The few notices appended will serve to indicate the hearty approval accorded to the unrevised 
edition on its appearance some years since: — 



There is so much that is instructive, even to the 
experienced practitioner, in their practical and dis- 
criminating manner of dealing with mooted ques- 
tions, none of which seem to be neglected; their 
abundant illustration*, drawn at once from an un 
limited field of hospital experience, and their candid 
and sensible mode of handling the whole subject, 
that these particular portions of the work possess a 
value which places them far above any publication 
on the same topics yet issued in the language.— Am. 
Journ. Mtd. Sciences. 

The enumeration of the treatises, and the names 
of the surgical writers from whose pens they pro- 
ceed, suffice to show that this is no ordinary book, 
and that in the thousand pages of this goodly volume 
lies a store of information such as no other surgical 
wjrk in the language can pretend to offer. Those who 
are acquainted with the special researches and pub- 
lications of the respective authors will not fail to 
notice tbat by a judicious exerci.-e of editorial dis- 
cretion, each subject has been entrusted, as far as 
possible, to a surgeon of the hospitals who is known 
to have given especial attention to it, and to possess 
facilities for summing up with authority the accepted 
opinions of the day, and adding original matter to 
the stock. — London Lnncct. 

The work must be considered a very complete ac- 
count of everything connected with the science and 
practice of surgery. In conclusion we can cordially 
recommend this work as a valuable addition to the 



■Edinburgh Medical Jour- 



lihrary of the surgeon. 
nal. 

It is a cyclopaedia of surgery of the most complete 
and extensive character; and we may justly state 
that its design and execution do great honor to those 
concerned, and that the large number and high 
standing of the authors selected for the various 
monographs render this "System" what it no doubt 
was intended to be, representative of the actual state 
of surgical science and art in the country. — London 
Lancet. 

In conclusion, we will add that we can most con- 
scienciously recommend the book to every medical 
practitioner. In recommending the " System, of Sur- 
gery 1 ' to our friends who have to deal in surgical 
cases, we by no means wish to confine our recom- 
mendation to them alone. Every practitioner of 
medicine may cull something worthy of note from a 
perusal of this volume.— The British Med. Journal. 

The four volumes remain a monument to the sur- 
gical genius of our day. The great majority of me- 
tropolitan surgeons of eminence and proved ability 
are represented in them ; and for many years to 
come, whoever wishes to know the most authori- 
tative words of English Surgical science on most 
subjects in the domaiu of surgery, must turn to these 
pages to read what there is tet forth. But taken as 
a whole it is the most important surgical work which 
has ever issued from the English press.— London 
Lancet. 



Henry C. Lea's Son & Co.'s Publications — (Surgery). 



T>RYANT {THOMAS), F.R.C.tS., 

*~) Sur g eon to Guy's Hospital. 

THE PRACTICE OF SURGERY. Third American, from the Sec- 

ond and Revised English Edition. Thoroughly revised and much improved, by John B. 
Roberts, M.D. In one large and very handsome imperial octavo volume of over 1000 
pages, with 672 illustrations. Cloth, $6 50; leather, $7 50 ; very handsome half Russia, 
raised bands, $8 00. {Just Ready.) 



Mr. Bryant's work has long been a favorite ODe 
with surgeons. As its name indicates, it is of a tho- 
roughly practical character. It is distinctly indi- 
vidual in that it gives the results of the author's 
large and varied experience as an operator and cli- 
nical teacher, and is on that account prized deserv- 
edly high as an original work. The style is neces- 
sarily condensed, the descriptions of surgical dis- 
eases brief and to the point. The illustrations are 
well chosen, and the typical cases of the author'6 
experience are full of interest, and are of more than 
oidinary value to the working surgeon.— N. Y. 
Medical Record, March 5, 1SS1. 

It is a work especially adapted to the wants of 
students and practitioners. While not prolix, it 
aff >rds instruction in sufficient detail for a full un- 
derstanding of surgical principles and the treat- 
ment of surgical diseases. It embraces in its scope 
all the diseases that are recognized as belonging to 
surgery, and all traumatic injuries. In discussing 
these it has seemed to be the aim of the author 
rather to present the student with practical infor- 
mation, and that alone, than to burden his memory 
with the views of different writers, however dis- 
tinguished they might have been. In this edition 



the whole work has been carefully revised, much 
of it has been rewritten, important additions have 
been made to almost every chapter. — Cincinnati 
Med. News. Jan. 1881. 

The En-glish edition, from which this is printed, 
has been carefully revised and rewritten; almost 
every chapter has received additions, and nearly 
one hundi-ed new cuts introduced. The labors of 
the American editor, Dr. John B Roberts, have 
very much increased the value of the book. He 
has introduced many new illustrations and much 
new material not found* in the English edition. 
He has written too with great conciseness, which 
is a rare virtue in an American editor of an English 
work. If one could procure or wished only one 
surgery, i his volume would certainly be selected. 
If he desired two, Erichien's Surgery would be 
added, and if he wished a third, Gross's Surgery 
would justly be the work selected. As the great 
work of Gross is amply sufficient for the waits of 
any surgeon, the priority given to Erichsen, and 
above all others, to this work of Bryant, is no 
labored eulogy of the last volume, but a simple and 
just statement of its demonstrable and pre-eminent 
merits.— Am. Med. Bi- Weekly, Feb. 26, 1881. 



WRIGESEN {JOHN E.), 

J_J professor of Surgery in University College, London, etc. 

THE SCIENCE AND ART OF SURGERY ; being a Treatise on Sur- 
gical Injuries, Diseases and Operations. Carefully revised by the Author from the 
Seventh and enlarged English Edition. Illustrated by eight hundred and sixty-two en- 
gravings on wood. In two large and beautiful octavo volumes of nearly 2000 pages : 
cloth, $8 50 ; leather, $10 50; half Russia, $11 50. (Now Ready.) 
Of the many treatises on Surgery which it has been 
our task to study, or our pleasure to read, there is none 
which in all points has satisfied us so well as the classic 
treatise of Erichsen. His polished, clear style, his free- 
dom from prejudice and hobbies, his unsurpassed grasp 
of his subject, and vast clinical experience, qualify him 
admirably to write a model text-book. When we wish 



at the least cost of time, to learn the most of a topic iD 
surgery, we turn, by preference, to his work. It is a 
pleasure, therefore, to see that the appreciation of it is 
geueral, and has led to the appearance of another edi 
tion. — Med. and Surg. Reporter, Feb. 2, 1878. 

Notwithstanding the increase in size, we observe that 
much old matter has been omitted. The entire work 
has been thoroughly written up, and not merely amend- 
ed by a few extra chapters. A great improvement has 
been made in the illustrations. One hundred and fifty 
new ones have been added, and many of the old ones 
have been redrawn. The author highly appreciates the 
favor with which his work has been received by Ameri- 
can surgeons, and has endeavored to render his latest 
edition more than ever worthy of their approval. That 
he has succeeded admirably, must, we think, be the 
general opinion. We heartily recommend the book to 
both student and practitioner. — JSf. Y.Med. Journal, 
Feb. 1878. 



The seventh edition is before the world as the last 
word of surgical science. There may be monographs 
which excel it upon certain points, but as a con- 
spectus upon surgical principles and practice it is 
unrivalled. It will well reward practitioners to 
read it, for it has been a peculiar province of Mr. 
Erichsen to demonstrate the absolute_,interdepend- 
ence of medical and surgical science. We need 
scarcely add, in conclusion, that we heartily com- 
mend the work to students that they may be 
grounded in a sound faith, and to practitioners as 
an invaluable guide at the bedside. — Am. Practi- 
tioner, April, 1878. 

For the past twenty years Erichsen's Surgery has 
maintained its place as the leading text- book, not only 
in this country, but in Great Britain. That'it is able 
to hold its ground, is abundantly proven by the tho- 
roughness with which the present edition has been 
revised, and by the large amount of valuable mate- 
rial that has been added. Aside from this, one hun- 
dred and fifty new illustrations have been inserted 
including quite a number of microscopical appear- 
ances of pathological processes, so marked is this 
change for the better, that the work almost appears 
as an entirely new one. — Med. Record, Feb. 23, 1878. 



fJOLMES (TIMOTHY), M.D. , 

-*■-*■ Surgeon to St. George's Hospital, London. 

SURGERY, ITS PRINCIPLES AND PRACTICE. In one hand- 
some octavo volume of nearly 1000 pages, with 411 illustrations. Cloth, $6; leather $7 • 
half Russia, $7 50. . 

its force and distinctness.— N. Y. Med. Record, April 
14, 1876. 

It will be found a most excellent epitome of sur- 
gery by the general practitioner who has not the 
time to give attention to more minute and extended 
works, and tothemedicalstudent. Infact, weknow 
of no one we can more cordially recommend. The 
author has succeeded well in giving a plain and 
practical account of each surgical injury and dis- 
ease, and of the treatment which is most com- 
monly advisable. It will no doubt become a popu- 
lar workin the profession, and especially as a text- 
book. — Cincinnati Med. News, April, 1S76. 



This is a work which has been lookedfor on both 
sides ofthe Atlantic with muchinterest. Mr. Holmes 
is a surgeon of large and varied experience, and one 
of the best known, and perhaps the most brilliant 
writer upon surgical subjects in England. It is a 
book for students — and an admirable one — and for 
the busy general practitioner. It will give a student 
all the knowledge needed to pass a rigid examina- 
tion. The book fairly justifiesthe high expectations 
that were formed of it. Its style is clear and forcible, 
even brilliant at times, and the conciseness needed 
to bring it withinits proper limitshas not impaired 



Henry C. Lea's Son & Co.'s Publications— (Ophthalmology). 29 



I/FELLS {J.SOELBERG), 

» * Professor of Ophthalmology in King' 1 8 College Hospital, <$se . 

A TREATISE ON DISEASES OF THE EYE. Third American, 

from the Third London Edition. Thoroughly revised, with copious additions, by Chns. 
S. Bull, M D. , Surgeon and Pathologist to the New York Eye and Ear Infirmary. Illus- 
trated with about 250 engravings on wood, and six colored plates Together with selec- 
tions from the Test-types of Jaeger and Snellen. In one large and very handsome 
octavo volume of 900 pages. Cloth, $5 ; leather, $6; half Rus&ia, raised bands, $6 50. 
(Just Ready.) 
The long-continued illness of the author, with its fatal termination, has kept this work for 
some time out of print, and has deprived it of the advantage of the revision which he sought 
to give it during the last years of hi- life. This edition has therefore been placed under the 
editorial supervision of Dr. Bull, who has labored earnestly to introduce in it all the advances 
which observation and experience have acquired for the theory and practice of ophthalmology 
since the appearance of the last revision. To accomplish this, considerable additions have been 
required, and the work is now presented in the confidence that it will fully deserve a continu- 
ance of the very marked favor with which it has hitherto been greeted as a complete, but con- 
cise, exposition of the principles and facts of its important department of medical science. 

The additions made in the previous American editions by Dr. Hays have been retained, 
including the very full series of illustrations and the test-types of Jaeger and Snellen. 



This new edition of Dr. Wells's great wurk on the 
eye will be welcomed by the profession at large ai- 
weli as by the oculist It contains much new matter 
relating to treatment and pathology , aud is brought 
thoroughly up with the pre-ent status of ophthal- 
mology. Its chapter on relr&etion and accommo- 
dation — a subject much discussed of late years, and 
of great importance— is exceedingly complete. — 
Louisville Med. News, Nov. 13, 1SS0. 

The merits of Wells's treatise on diseases of the 
eye have been so universally acknowledged, and are 
so familiar to all who profess to have given any at- 
tention to ophthalmic surgery, that any discussion 
of them at this late day will be a work of superero- 
gation. Very little that is practically useful in re- 
cent ophthalmic literature has escaped the editor, 
and the third American edition is well up to the 
times. As a text-book on ophthalmic surgery for the 
English-speakiug practitioner, it is without a rivai. 
— Am.Joum. of Med. Set., Jan. 1881. 

The work has justly held a high place in English 
ophthalmic literature, and at the time of its first ap- 
pearance was the best treatise of its kind in the lan- 



guage. In the tecond edition, the author showed 
industrious research in adding new material from 
every quarter, aud his spirit was eminently caudid. 
A work thus built up by honest effort should not be 
suffered to die, and we are pleased to receive this 
third edition from the hands of Dr. Bull. His labor 
h ts been arduous, as the very great number of addi- 
tions bracketed- with his initial testify. Under 
the editorship which the third edition has enjoyed, 
the work is sure to sustain its good repuiation, and 
to maintain its usefulness. — N. Y. Mea.Journ., Jan. 
18S1. 

There is really no work which approaches it in 
adaptatiou to the wants of the general practitioner, 
wiule.the most advanced specialist cannot ri*e from 
a perusal of its ample pages without having added 
to his knowledge. The American editor, Dr. Bull, 
won his spurs in ophthalmology some time back. 
His additions 10 the work of the lamented Wells are 
many, judicious, and timely, and in just so much 
have added to its value.— Am. Practiiiontr, Jan. 
1881. 



KTETTLESHIP {EDWARD), F.R.G.S., 

-*- * Ophthalmic Surg, and Lect. on Ophth. Surg, at St. Thomas' 1 Hospital, London. 

MANUAL OF OPHTHALMIC MEDICINE. In one royal 12mo. 

volume of over 350 pages, with 89 illustrations. Cloth, $2. {Just Ready.) 
The author is to be congratulated upon the very information they contain. We do not hesitate to 

pronounce Mr. Nettleship's book the best manual on 
ophthalmic surgery for the use of students and 
" busy practitioners" with which we are acquain- 



successful manner in which he has accomplished his 
task; he has succeeded iu being concise without 
sacrificing clearness, and, including the whole 
ground covered by more voluminous text-books, 
has given an excellent re'sume' of all the practical 



ted.— Am. Jour. Med. Sciences, April, 1S80. 



c- 



'ARTER {R. BRUDENELL), F.R.C.8., 

Ophthalmic Surgeon to St. George's Hospital, etc. 

A PRACTICAL TREATISE ON DISEASES OF THE EYE. Edit- 
ed, with test-types and Additions, by John Green, M.D. (of St. Louis, Mo.). In one 
handsome octavo volume of about 500 pages, and 124 illustrations. Cloth, $3 75. 



It is with great pleasure that we can endorse the work 
as a most valuable contribution to practical ophthal- 
mology. Mr. Carter never deviates from the end he has 
in view, and presents the subjectin a clear and concise 
maimer, easy of comprehension, and heuce the more 
valuable. We would especially commend, however, as 
worthy of high praise, the manner iu which the thera- 
peutics of disease of the eye is elaborated, for here the 
author is particularly clear and practical, where other 
writers are unfortunately too often deficient. The final 



chapter is devoted to a discussion oi the uses and selec- 
tion ofspectaoles.andis admirably compact, plain, and 
useful, especially the paragraphs on the treatment of 
presbyopia and myopia. In conclusion, our thanks are 
due the author for many useful hints in the great sub- 
ject of ophthalmic surgery and therapeutics, afield 
whereof late years we glean but a few grains of sound 
wheat from amass of chaff. — New York Medical Record, 
Oct. 23, 1875. 



B 



ROWNE {EDGAR A.), 

Surgeon to the Liverpool Ey e and Ear Infirmary , and to the Dispensary for Skin Diseases. 

HOW TO USE THE OPHTHALMOSCOPE. Being Elementary In- 

structionsin Ophthalmoscopy, arranged for the Use of Students. With thirty-five illustra- 
tions. In one small volume royal 12mo. of 120 pages : cloth, $1. 



LAURENCE'S HANDST-BOOK OF OPHTHALMIC 
SURGERY, for the use of Practitioners. Second 
edition, revised and enlarged With numerous 
illustrations. In one very handsome octavo vol- 
ume, cloth, $2 76. 



LAWSON'S INJURIES TO THE EYE, ORBIT 
AND EYELIDS: their Immediate and Remote 
Effects. With about one hundred illustrations. 
la one very handsome octapu volume, cloth 
$3 60. 



30 Henry C. Lea's Son & Co.'s Publications — (Med. Jurisprudence). 
jyUENETT {CHARLES H.), M. A , M.D., 

•*-* Aural Surg, to the Presb. Bosp., Surgeon-in- charge ofthelnfir.forDis. of the Ear, Phila. 

THE EAR, ITS ANATOMY, PHYSIOLOGY AND DISEASES. 

A Practical Treatise for the Use of Medical Students and Practitioners. In one hand- 
some octavo volume of 615 pages, with eighty-seven illustrations: cloth, $4 50 ; leather, 
$5 50 ; half Russia, $6 00. {Lately Issued.) 
Foremost among the numerous recent contribu- 
tions to aural literature will be ranked this work 
of Dr. Burnett. It is impossible to do justice to 
this volume of over 600 pages in a necessarily brief 



notice. It must suffice to add that the book is pro- 
fusely and accurately illustrated, the references are 
conscientiously acknowledged, while the result has 
been to produce a treatise which will henceforth 
rank with the classic writings of Wilde and Von 
Troltsch. — The Lond. Practitioner, May, 1879. 

On account of the great advances which have been 
made of late years in otology, and of the increased 
interest manifested in it, the medical profession will 
welcome this new work, which presents clearly and 
concisely its present aspect, whilst clearly indi- 
cating the direction in which further researches can 
be most profitably carried on. Dr. Barm tt from his 
own matured experience, and availing himself of 



the observations and discoveries of others, has pro- 
duced a work which, as a text-book, stands facile 
prineeps in our language. We had marked several 
pa -sages as well worthy of quotation and the atten- 
tion of the general practitioner, but their number and 
the space at our command forbid. Perhaps it is bet- 
ter, as the book ought to be in the hands of every 
medical student, and its study will well repay the 
busy practitioner in the pleasure he will derive from 
the agreeable style in which many otherwise dry 
and mostly unknown subjects are treated. To the 
specialist the work is of the highest value, and his 
sense of gratitude to Dr. Burnett will, we hope, be 
proportionate to the amount of benefit he can obtain 
from the careful study of the book, and a constant 
reference to its trustworthy pages. — Edinbu gh 
Med. Jour., Aug. 1878. 



'AFLOR {ALFRED S.),M.D., 

Lecturer on Med. Jurisp. and Chemistry in Guy's Hospital. 

A MANUAL OF MEDICAL JURISPRUDENCE. Eighth Ameri- 
can edition. Thoroughly revised and rewritten. Edited by John J. Reese, M.D., Prcf. 
of Med. Jurisp. and Toxicology in the Univ. of Penn. In one large octavo volume of 
933 pages, with 70 illustrations. Cloth, $5; leather, $6; half Russia, raised bands, 
$6 50. {Just Ready.) 



The American editions of this standard manual 
have for a lon^j time laid claim to the attention of 
the profession in this country ; and that the profes- 
sion has recognized this claim with favor is proven 
by the call for frequent new editions of the work. 
This one, the eighth, comes before us as embodying 
the latest thoughts and emendations of Dr. Taylor, 
upon the subject to which he devo.ed his life, with 
an assiduity and success which made him facil", 
prinr-eps among English writers on medical juris- 
prudence. Both the author and the book have 
made a mark too deep to be affected by criticism, 
whether it he censure or praise. In this case, how- 
ever, we should only have to seek for laudatory 
teims.— Am. Journ. of Med. Sci., Jan. 1SS1. 

It is not very often that a medical book reaches its 
tenth edition, or that the last earthly labor is per- 
formed by the author in retouching the work that 
first came from his hand thirty-five years before. 
All this, however, has happened in the ca-e of Dr. 



is to announce, not criticize the completed task. The 
value of the gem is too well known to requiie more 
than the telling chat the mister-hand has rebright- 
ened its facets and polished its angles before leaving 
it as his legacy to h*s brethren in the profession. — 
Phila M<id. Times, Dec. 4, 1880. 

It will suffice to remarK that this new edition 
shows the signs of judicious revision. A great num- 
ber of illustrative medico- legal cases which have 
occurred since the last edition was published are 
cited in .heir proper connection, and add much to 
the interest and value of the work; they comprise 
the bulk; of the additions to the text. As an indica- 
tion of the creshnesi of the work, we notice numer- 
ous references to medicolegal experience that has 
transpired during the year just ended ; among these 
is a comment by the American editor upon that 
midsummer madness, the Tanner fasting exploit of 
last August. In these features and in others there 
is ample evidence that this admirable book will 



Taylor and his classical treatise. The pen dropped maintain its hi^h place as a standard authority cou- 
from the grasp only when the shadows of old age i cerning the matters of which it treats. —Boston 
were rapidly deepening into the darkness of death. Med. and Surg. Journal, Jan. 13, 1S81. 
Under the circumstances, all the journalist has to do [ 



T>Y THE SAME AUTHOR. 

THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- 

DENCE. Second Edition, Revised, with numerous Illustrations. In two large octavo 

volumes, cloth, $10 00 ; leather, $12 00 
This great work is now recognized in England as the fullest andmostauthoritativetreatise on 
every department of its important subject. In laying it, in its improved form, before the Amer- 
ican profession, the publishers trust that it will assume the same position in this country. 

T>T THE SAME AUTHOR. 

POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND 

MEDICINE. Third American, from the Third and Revised English Edition. In one 
large octavo volume of 850 pages ; cloth, $5 50 ; leather, $6 50. 



The present is based upon the two previous edi- 
tions ; "but the complete revision rendered necessary 
by time has converted it into a new work." This 
statement from the preface contains all that it is de- 
sired to know in reference to the new edition The 
works of this author are already in the library of 
every physician«vho is liable to be called upon for 
medico-legal testimony (and whatuneis not?) ; sothat 
all that is required to be known about the present 
book is that the author has kept it abreast with the 
times. What makes it now, as always, especially 
valuable to the practitioner is its conciseness ana 
practical character, only those poisonous substances 



being described which give rise to legal investiga- 
tions.— The Clinic, Nov. 6, 1875. 

Dr. Taylor has brought to bear on the compilation 
of this volume, stores of learning, experience, and 
practical acquaintance with his subject, probably far 
beyond what any other living authority on toxicol- 
ogy could have amassed or utilized. He has fully 
sustained his reputation by the consummate skill 
and legal acumen he has displayed in the arrange- 
ment of the subject-matter, and the result is a work 
on Poisons which willbeindispensable to every stu- 
dent or practitioner in lawand medicine. — The Dub. 
tin Journ. of Med Set., Oct. 1S75. 



Henry C. Lea's Son & Co.'s Publications — {Miscellaneous). 31 



ROBERTS [WILLIAM), M.D., 

-*•*' Lecturer on Medicine in the Manchester School of Medicine, etc. 

A PRACTICAL TREATISE ON URINARY AND RENAL DIS- 
EASES, including Urinary Deposits. Illustrated by numerous cases and engravings. Third 
American, from the Third Revised and Enlarged London Edition. In one large and 
handsome octavo volume of over 600 pages. Cloth, $4. (Just Beady.) 

THOMPSON {SIR HENRY), 

■*• Surgeon and Professor of Clinical Surgery to University College Hospital . 

LECTURES ON DISEASES OF THE URINARY ORGANS. With 

illustrations on wood.' Second American from the Third English Edition. In one neat 
octavo volume. Cloth, $2 25. 
T>Y THE SAME AUTHOR. 

ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF 

THE URETHRA AND URINARY FISTULA. With plates and wood-cuts. From the 
third and revised English edition. In one very handsome octavo volume, cloth, $3 50. 

rrjJKE {DANIEL BACK), M.D., 

J- Joint author of The Manual of Psychological Medicine, &c. 

ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON 

THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of the 
Imagination. In one handsome octavo volume of 416 pages, cloth, $3 25. 

J>LANDFORD {O. FIELDING), M.D., F.R.C.P., 

•U Lecturer on Psychological Medicine at the School of St. George'' s Hospital, Ac. 

INSANITY AND ITS TREATMENT: Lectures on the Treatment, 

Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the 
United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very 
handsome octavo volume of 471 pages ; cloth, $3 25. 



It satisfies a want which must have been sorely 
felt by the busy general practitioners of this country. 
It takes the form of a manual ofclinicaldescription 
of the various forms of insanity, with a description 
of the mode of examining persons suspected of in- 
sanity. We call particularattentionto this feature 
of the book, as givingit a unique value to the gene- 
ral practitioner. If we pass from theoretical conside- 
rations to descriptions of the varietiesof insanityas 



actually seen in practice and the appropriate treat- 
ment for them, we find in Dr. Blandford'^ work a 
considerable advanceover previous writings on the 
subject. His pictures of the various forms of mental 
disease are so clear and good that no reader can fail 
to be struck withtheir superiority to thosegiven in 
ordinary manuals in the English language or (so far 
as our own reading extendsjinany other.— London 
Practitioner, Feb. 1871. 



EA {HENRY C). 
SUPERSTITION AND FORCE: ESSAYS ON THE WAGER OF 

LAW, THE WAGER OF BATTLE, THE ORDEAL AND TORTURE. Third Revised 
and Enlarged Edition. In one handsome royal 12mo. volume of 552 pages. Cloth, 
$2 50. (Just Ready.) 



This valuable work is in reality a history of civi- 
lization as interpreted by the progress of jurispru- 
dence. . . . In "Saperstition and Force" we have 
a philosophic survey of the loug period iuterveni ng 
between primitive barbarity and civilized enlight- 
enment. There is not a chapter in the work that 
should not be most carefully studied, and however 
well versed the reader may be in the science of 
jurisprudence, he will find much in Mr. Lea's vol- 
ume of which he was previously ignorant. The 
book is a valuable addition to the literature of 
social science.— Westminster Review, Jan. 1880. 

The appearance of a new edition of Mr. Henry C. 
Lea's "Superstition and Force" is a sign that our 
highest scholarship is not without honor in its na- 
ti /e country. Mr. Lea has met every fresh demand 
for his work with a careful revision of it, and the 
present edition is not only fuller and, if possible, 



more accurate than either of the preceding, but, 
from the thorough elaboration, is more like a har- 
monious concert and less like a batch of studies. — 
The Nation, Aug. 1, 1878. 

Many will be tempted to say that this, like the 
••DeclineandFall,"isone of theuncriticizable books. 
Its facts are innumerable, its deductions simple and 
inevitable, and its chevaux-de-frise of references 
bristling and dense enough to make the keenest, 
stoutest, and best equipped assailant think twice 
before advancing. Nor is there anything contro- 
versial in it to provoke assault. The author is no 
polemic. Though he obviously feels and thinks 
strongly, he succeeds in attaining impartialitv. 
Whether looked on as a picture or a mirror, a work 
such as this has a lasting value. — LippincotV s 
Magazine, Oct. 1878. 



D7 THE SAME AUTHOR. 

STUDIES IN CHURCH HISTORY. THE RISE OF THE TEM- 
PORAL power— benefit of CLERGY— EXCOMMUNICATION. In one large 
royal l2mo. volume of 516 pp.; cloth, $2 75. (Lately Published.) 

has a peculiarimportance for the English student,and 
is a chapter on Ancient Law likely to be regarded as 
final. We can hardly pass from our mention of such 
works as these— with which that on "Sacerdotal 
Celibacv" should be included — without noting the 
literary phenomenon that the head of one of the first 



The story was never told more calmly or with 
greater learning or wiser thought. We doubt, indeed, 
if any other study of this field can be compared with 
this for clearness, accuracy, and power. — Chicago 
Examiner, Dec. 1870. 

Mr. Lea's latest work," Studiesin Church History," 
fully sustains the promise of the first. It deals with 
three subjects — the Temporal Power, Benefit of 
Clergy, and Excommunication, the record of which 



American houses is also the writer of some of its most 
original books. — London Athenceum, Jan. 7,1S71. 



32 



Henry C. Lea's Son & Co.'s Publications. 



INDEX TO CATALOGUE 



American Journal of the Medical Sciences 

Allen's Anatomy 

Anatomical Atlas, by Smith and Horner 
Ashton on the Rectum and Anas 
Attiieid's Chemistry .... 
Ashwell on Diseases of Females 

*A.shhurst's Surgery .... 
Browne on Ophthalmoscope . 
Browne on the Throat .... 

*Burnett on the Ear .... 

*3arnes on Diseases of Women . 
Barnes' Midwifery .... 

Bellamy's Surgical Anatomy 

*Bryant's Practice of Surgery . 

Bloxam's Chemistry .... 

Blandford on Insanity .... 

Basham on Renal Diseases . 

Bartholow on Electricity 

Barlow's Practice ol Medicine . 

Bowman's (John E.)Practical Chemistrj 

*Bristowe's Practice . 

*Bumstead on Venereal 

Bumstead and Cullerier's Atlasof Venereal 

^Carpenter's Human Physiology 

Carpenter on the Use and Abuse of Alcohol 

*Cornil and Ranvier ... 

Carter on the Eye 

Clelaud's Dissector .... 

Classen's Chemistry .... 

Clowes' Chemistry .... 

Coleman's Dental Surgery . 

Century of American uieuicine . 

Chadwick on Diseases of Women 

Chambers on Diet and Regimen . 

Christisonand Griffith's Dispensatory 

Churchill on Puerperal Fever 

Condie on Diseases of Children . 

Cooper's (B. B.) Declares on Surgery 

Cullerier's Atlas of Venereal Diseases 

Duncan on Diseases of Women . 

*Dalton's Human Physiology 

Davis's Clinical Lectures 

Dewees on Diseases of Females . 

Druitt's ModernSurgery 

*Dunglison's Medical Dictionary 

Edis on Diseases of Women . 

Ellis's Demonstrations in Anatomy 

*Erichsen's System of Surgery . 

*Emmet on Diseases of Women . 

Farquharson's Therapeutics 

Foster's Physiology 

Fenwick's Diagnosis .... 

Finlayson's Clinical Diagnosis . 
Flint on Respiratory Organs 
Flint on the Heart .... 
^Flint's Practice of Medicine. 
Flint's Essays 

^Flint's Clinical Medicine . 

Flint on Phthisis 

Flint on Percussion .... 

*FothergiH's Handbook of Treatment 

Fownes's Elementary Chemistry 

Fox on Diseases of the Skin 

Fuller on the Lungs, &c. 

Green's Pathology and Morbid Anatomy 

Greene's Medical Chemistry 

Gibson's Surgery 

Gluge's Pathological Histology, by Leidy 

*Gray's Anatomy, 

Galloway's Analysis .... 
Griffith's (R. S.) Universal Formulary 

Gross on Sterility 

Gross on Urinary Organs . 

Gross on Foreign Bodies in Air-Passages 

*3ross's System of Surgery 

Habershon on the Abdomen . 

^Hamilton on Dislocations and Fractures 

Hartshorne's Essentials of Medicine 

Hartshorne's Conspectus of the Medical Sciences 

Hartshorne's Anatomy and Physiology 

Hamilton on Nervous Diseases .' 

Hoffman's Chemical Analysis 

Heath's Practical Anatomy 

Hoblyn's Medical Dictionary . 

Hodce on Women .... 

Hodg6's Obstetrics 



PAGE 

. 1 

. 7 

. 7 



2\ 



PAGB 
Holland's Medical Notesand Reflections . 14 

*Holmes' System of Surgery . . . .27 
*Holmes's Surgery . .... 28 

Holden's Landmarks ..... 6 

Horner's Anatomy and Histology ... 7 

Hudson on Fever 20 

Hill on Venereal Diseases 20 

Hillier's Handbook of Skin Diseases . . 19 
Jones (C. Handheld) on Nervous Disorders . 19 
Knapp's Chemical Technology .... 10 
Keating on Infants 21 



. 25 

. 20 

. 23 

. 8 

, 15 

. 21 



Lea's Superstition and Force . . 

Lea's Studies in Church History 

Lee on Syphilis 

*Leishman's Midwifery 

La Roche on Yellow Fever. 

La Roche on Pneumonia, &c. 

Laurence and Moon's Ophthalmic Surgery . 29 

Lawson on the Eye ... ... 29 

Lehmann's Physiological Chemistry, 2 vols 

Lehmann's Chemical Physiology 

Ludlow's Manual of Examinations . 

Lyons on Fever . . . 

Maisch's Materia Medica 

Mitchell's Nervous diseases of Women 

Medical News and Abstract 

Morris on Skin Diseases 

Meigs on Puerperal Fever . 

Bliller's Practice of Surgery 

Miller's Principles of Surgery . 

Montgomery on PregDancy 

Nettleship's Ophthalmic Medicine 

Neiliand Smith's Compendium of Med .Science 

Parkin's Midwifery .... 

Parry on Extra-Uterine Pregnancy . 

Pavy on Digestion 

*Parrish's Practical Pharmacy . 

Pirrie's System of Surgery . 

*Playfair'g Midwifery .... 

Quain and Sharpey's Anatomy, by Leidy 

^Reynolds' System of Medicine . 

Richardson's Preventive Medicine 

Roberts on Urinary Diseases 

Ramsbotham on Parturition 

Remsen's Principles of Chemistry 

Rigby's Midwifery .... 

Rodwell's Dictionary of Science . 

Stimson's Operative Surgery 

Swayne's Obstetric Aphorisms . 

Seiler on the Throat 

Sargent's Minor Surgery 

Sharpey and Quain's Anatomy, by Leidy 

Skey's Operative Surgery . 

Slade on Diphtheria .... 

Schafer's Histology .... 

*Siuith (J. L.) on Children . 

Smith (H. H.) and Horner's Anatomical Atlas 

Smith (Edward) on Consumption 

Smith (Enst ) on Wasting Diseases in Children 

*Still6's Therapeutics .... 

*Stille & Maisch's Dispensatory . 

Sturges on Clinical Medicine 

Stokes on Fever 

Tanner's Manual of Clinical Medicins 

Tanner on Pregnancy .... 

*Taylor's Medical Jurisprudence 

Taylor's Principles and Practice of Med 

Taylor on Poisons 

Tuke on the Influence of the Mind 

"^Thomas on Diseases of Females 

Thompson on Urinary Organs 

Thompson on Stricture . 

Todd on Acute Diseases 

Woodbury's Practice .... 

Walshe on the Heart .... 

Watson's Practice of Physic 

* Wells on the Eye .... 

West on Diseases of Females 

Weston Diseases of Children 

West on Nervous Disorders of Children 

Williams on Consumption . 

Wilson's Human Anatomy . 

Wilson's Handbook of Cutaneous Medicin 

Wohler's Organic Chemistry . 

Winckel on Childbed .... 



risp 



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5 

20 

13 

IS 

2 
19 
•Jl 
25 
25 
21 
29 

5 
24 
23 
14 
31 
25 
24 

7 
37 
16 
31 
23 

9 
21 

4 
25 
21 
19 
26 

7 
25 
16 

7 
21 

7 
16 
20 
13 
12 
15 
14 

5 
23 
30 
30 
30 
31 
22 
31 
31 
14 
16 

id 

16 
29 
21 
21 
21 
16 

7 
20 

9 
21 



Books marked * are also bound in half Russia. 



HENRY C. LEA'S SON & CO.— Philadelphia. 



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